Provider Demographics
NPI:1144581307
Name:STANSBURY PARK DENTAL CARE
Entity Type:Organization
Organization Name:STANSBURY PARK DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-882-2850
Mailing Address - Street 1:263 COUNTRY CLB
Mailing Address - Street 2:#103
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9600
Mailing Address - Country:US
Mailing Address - Phone:435-882-2850
Mailing Address - Fax:435-843-8852
Practice Address - Street 1:263 COUNTRY CLB
Practice Address - Street 2:#103
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9600
Practice Address - Country:US
Practice Address - Phone:435-882-2850
Practice Address - Fax:435-843-8852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3698731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty