Provider Demographics
NPI:1295398352
Name:CACHE VALLEY DENTAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:CACHE VALLEY DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-232-1232
Mailing Address - Street 1:2797 N HIGHWAY 89 STE 300
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84404-1232
Mailing Address - Country:US
Mailing Address - Phone:801-786-0500
Mailing Address - Fax:
Practice Address - Street 1:120 W CACHE VALLEY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2697
Practice Address - Country:US
Practice Address - Phone:435-753-7563
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty