Provider Demographics
NPI:1205401973
Name:RALLISON DENTAL LLC
Entity Type:Organization
Organization Name:RALLISON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:MONTY
Authorized Official - Last Name:RALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-663-6451
Mailing Address - Street 1:183 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-2395
Mailing Address - Country:US
Mailing Address - Phone:801-825-1822
Mailing Address - Fax:
Practice Address - Street 1:183 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-2395
Practice Address - Country:US
Practice Address - Phone:801-825-1822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1891144739Medicaid