Provider Demographics
NPI:1265664072
Name:STONE CREEK FAMILY DENTAL
Entity Type:Organization
Organization Name:STONE CREEK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-253-4547
Mailing Address - Street 1:2332 W 12600 S STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7172
Mailing Address - Country:US
Mailing Address - Phone:801-253-4547
Mailing Address - Fax:
Practice Address - Street 1:2332 W 12600 S STE A
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7172
Practice Address - Country:US
Practice Address - Phone:801-253-4547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty