Provider Demographics
NPI:1346458932
Name:LIDDELL FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LIDDELL FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-733-0406
Mailing Address - Street 1:702 E SOUTH TEMPLE STE 209
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1795
Mailing Address - Country:US
Mailing Address - Phone:801-359-8282
Mailing Address - Fax:
Practice Address - Street 1:702 E SOUTH TEMPLE STE 209
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1795
Practice Address - Country:US
Practice Address - Phone:801-359-8282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT512081-99221223G0001X
UT22-13695-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty