Provider Demographics
NPI:1225249683
Name:SOUTHRIDGE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTHRIDGE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-446-1515
Mailing Address - Street 1:2651 W. 10400 S. #103
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095
Mailing Address - Country:US
Mailing Address - Phone:801-445-1515
Mailing Address - Fax:801-446-5290
Practice Address - Street 1:2651 W. 10400 S. #103
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-445-1515
Practice Address - Fax:801-446-5290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT343291122300000X
UT5667938122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty