Provider Demographics
NPI:1306391180
Name:AFFLECK RESTORATIVE & PROSTHETIC DENTISTRY
Entity Type:Organization
Organization Name:AFFLECK RESTORATIVE & PROSTHETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AFFLECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-782-5010
Mailing Address - Street 1:2537 N WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-7244
Mailing Address - Country:US
Mailing Address - Phone:801-782-5010
Mailing Address - Fax:
Practice Address - Street 1:2537 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7244
Practice Address - Country:US
Practice Address - Phone:801-782-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty