Provider Demographics
NPI:1457476376
Name:PROFESSIONAL DENTAL LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-785-8000
Mailing Address - Street 1:PO BOX 1715
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1715
Mailing Address - Country:US
Mailing Address - Phone:801-785-8000
Mailing Address - Fax:801-465-9475
Practice Address - Street 1:78 E 100 S
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-2262
Practice Address - Country:US
Practice Address - Phone:801-465-0550
Practice Address - Fax:801-465-9475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT569282801601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty