Provider Demographics
NPI:1154637825
Name:GRANGER PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:GRANGER PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:J
Authorized Official - Last Name:HORGESHEIMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-969-8881
Mailing Address - Street 1:P.O. BOX 18430
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-0430
Mailing Address - Country:US
Mailing Address - Phone:801-969-8881
Mailing Address - Fax:801-969-8889
Practice Address - Street 1:3725 W. 4100 S.
Practice Address - Street 2:SUITE #260
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-969-8881
Practice Address - Fax:801-969-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT360305-9923261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT526155793003Medicaid