Provider Demographics
NPI:1245607068
Name:MAIN STREET DENTAL OF SALT LAKE CITY
Entity Type:Organization
Organization Name:MAIN STREET DENTAL OF SALT LAKE CITY
Other - Org Name:MAIN STREET DENTAL OF SALT LAKE CITY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-792-6033
Mailing Address - Street 1:7922 S GOLDENPOINTE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7672
Mailing Address - Country:US
Mailing Address - Phone:801-792-6033
Mailing Address - Fax:
Practice Address - Street 1:3195 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3749
Practice Address - Country:US
Practice Address - Phone:801-792-6033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service