Provider Demographics
NPI:1215364476
Name:GRANDPAS DENTAL CARE OF UTAH LLC
Entity Type:Organization
Organization Name:GRANDPAS DENTAL CARE OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-576-1444
Mailing Address - Street 1:53 W 10600 S
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4160
Mailing Address - Country:US
Mailing Address - Phone:801-576-1444
Mailing Address - Fax:
Practice Address - Street 1:53 W 10600 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4160
Practice Address - Country:US
Practice Address - Phone:801-576-1444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental