Provider Demographics
NPI:1144422429
Name:GRANDPA'S DENTAL INC.
Entity Type:Organization
Organization Name:GRANDPA'S DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-5100
Mailing Address - Street 1:777 NORTH 500 WEST
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1570
Mailing Address - Country:US
Mailing Address - Phone:801-374-5100
Mailing Address - Fax:
Practice Address - Street 1:777 NORTH 500 WEST
Practice Address - Street 2:201B
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1570
Practice Address - Country:US
Practice Address - Phone:801-374-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty