Provider Demographics
NPI:1407112469
Name:MIDVALE MODERN DENTISTRY, LLP
Entity Type:Organization
Organization Name:MIDVALE MODERN DENTISTRY, LLP
Other - Org Name:MIDVALE MODERN DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SWENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-566-3118
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:1144 EAST FORT UNION BOULEVARD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-566-3118
Practice Address - Fax:801-561-1343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty