Provider Demographics
NPI:1114190659
Name:IZZY INC.
Entity Type:Organization
Organization Name:IZZY INC.
Other - Org Name:THE CENTER OF DENTAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MCCUTCHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-747-8012
Mailing Address - Street 1:530 E 500 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102
Mailing Address - Country:US
Mailing Address - Phone:801-747-8000
Mailing Address - Fax:801-747-8001
Practice Address - Street 1:530 E 500 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102
Practice Address - Country:US
Practice Address - Phone:801-747-8000
Practice Address - Fax:801-747-8001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IZZY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-04
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT022824566005Medicaid
UT5295997150001Medicaid
UT1114118601Medicaid
UT278683018001Medicaid