Provider Demographics
NPI: | 1376656017 |
---|---|
Name: | SMILEWIDE DENTAL CARE PC |
Entity Type: | Organization |
Organization Name: | SMILEWIDE DENTAL CARE PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DOCTOR |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RODNEY |
Authorized Official - Middle Name: | JONATHAN |
Authorized Official - Last Name: | THORNELL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 801-446-6889 |
Mailing Address - Street 1: | 5629 W. 13100 S. |
Mailing Address - Street 2: | |
Mailing Address - City: | HERRIMAN |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84096 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-446-6889 |
Mailing Address - Fax: | 801-446-6881 |
Practice Address - Street 1: | 5629 W. 13100 S. |
Practice Address - Street 2: | |
Practice Address - City: | HERRIMAN |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84096 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-446-6889 |
Practice Address - Fax: | 801-446-6881 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-08-16 |
Last Update Date: | 2016-05-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 53235209922 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |