Provider Demographics
NPI:1346760097
Name:ABUNDANT DENTAL CARE, P.C.
Entity Type:Organization
Organization Name:ABUNDANT DENTAL CARE, P.C.
Other - Org Name:RIVERTON DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTS RECEIVABLE
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-849-1045
Mailing Address - Street 1:793 E WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3409 W 12600 S STE 100
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7266
Practice Address - Country:US
Practice Address - Phone:801-561-1559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABUNDANT DENTAL CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-23
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherN/A