Provider Demographics
NPI:1114148509
Name:PINEBROOK DENTAL GROUP
Entity Type:Organization
Organization Name:PINEBROOK DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-649-6688
Mailing Address - Street 1:3080 PINEBROOK RD
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5422
Mailing Address - Country:US
Mailing Address - Phone:435-649-6688
Mailing Address - Fax:435-649-0654
Practice Address - Street 1:3080 PINEBROOK RD
Practice Address - Street 2:SUITE 2000
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5422
Practice Address - Country:US
Practice Address - Phone:435-649-6688
Practice Address - Fax:435-649-0654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT380199122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty