Provider Demographics
NPI:1164568952
Name:IVERSON, CLINT G (DMD)
Entity Type:Individual
Prefix:DR
First Name:CLINT
Middle Name:G
Last Name:IVERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 COMBE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5013
Mailing Address - Country:US
Mailing Address - Phone:801-475-1999
Mailing Address - Fax:801-475-1888
Practice Address - Street 1:1770 COMBE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5013
Practice Address - Country:US
Practice Address - Phone:801-475-1999
Practice Address - Fax:801-475-1888
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47586521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice