Provider Demographics
NPI:1336465830
Name:SOUTH VALLEY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTH VALLEY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CATMULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-489-1301
Mailing Address - Street 1:1795 W. 500 S.
Mailing Address - Street 2:SUITE B3
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663
Mailing Address - Country:US
Mailing Address - Phone:801-489-1301
Mailing Address - Fax:
Practice Address - Street 1:1795 W 500 S
Practice Address - Street 2:SUITE B3
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3186
Practice Address - Country:US
Practice Address - Phone:801-489-1301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-09
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT582779657001Medicaid