Provider Demographics
NPI:1275859589
Name:LEGACY FAMILY DENTAL OF BOUNTIFUL LLC
Entity Type:Organization
Organization Name:LEGACY FAMILY DENTAL OF BOUNTIFUL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KASE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-870-0838
Mailing Address - Street 1:55 E 2200 S
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-5619
Mailing Address - Country:US
Mailing Address - Phone:801-295-5115
Mailing Address - Fax:801-397-5559
Practice Address - Street 1:55 E 2200 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5619
Practice Address - Country:US
Practice Address - Phone:801-295-5115
Practice Address - Fax:801-397-5559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT75313980160302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization