Provider Demographics
NPI:1164869913
Name:YOUNG FAMILY DENTAL-RIVERTON
Entity Type:Organization
Organization Name:YOUNG FAMILY DENTAL-RIVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-224-0222
Mailing Address - Street 1:12562 RHETSKI LN
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065
Mailing Address - Country:US
Mailing Address - Phone:801-446-2518
Mailing Address - Fax:
Practice Address - Street 1:12562 RHETSKI LN
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-446-2518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNG FAMILY DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-03
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4766943-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty