Provider Demographics
NPI:1104834191
Name:SOUTH OGDEN PEDIATRIC DENTAL P.C.
Entity Type:Organization
Organization Name:SOUTH OGDEN PEDIATRIC DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:M.
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:RALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-475-6433
Mailing Address - Street 1:5275 S. ADAMS AVE.,
Mailing Address - Street 2:SUITE C SUITE #4
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405
Mailing Address - Country:US
Mailing Address - Phone:801-475-6433
Mailing Address - Fax:801-334-8411
Practice Address - Street 1:5275 S. ADAMS AVE.,
Practice Address - Street 2:SUITE C
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405
Practice Address - Country:US
Practice Address - Phone:801-475-6433
Practice Address - Fax:801-334-8411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5118697-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT518155919002Medicaid