Provider Demographics
NPI:1114314747
Name:A PERFECT SMILE
Entity Type:Organization
Organization Name:A PERFECT SMILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BLANE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-210-2568
Mailing Address - Street 1:230 N FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4205
Mailing Address - Country:US
Mailing Address - Phone:435-637-2100
Mailing Address - Fax:435-637-5007
Practice Address - Street 1:230 N FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4205
Practice Address - Country:US
Practice Address - Phone:435-637-2100
Practice Address - Fax:435-637-5007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6605138261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental