Provider Demographics
NPI:1417739715
Name:HERITAGE PARK BOULEVARD DENTAL PLLC
Entity Type:Organization
Organization Name:HERITAGE PARK BOULEVARD DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:2719 US-89
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404
Mailing Address - Country:US
Mailing Address - Phone:801-782-5792
Mailing Address - Fax:801-782-3339
Practice Address - Street 1:2719 US-89
Practice Address - Street 2:SUITE 100
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404
Practice Address - Country:US
Practice Address - Phone:801-782-5792
Practice Address - Fax:801-782-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty