Provider Demographics
NPI:1457671299
Name:EAST MOUNTAIN DENTAL LLC
Entity Type:Organization
Organization Name:EAST MOUNTAIN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-377-0037
Mailing Address - Street 1:2335 S STATE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-6576
Mailing Address - Country:US
Mailing Address - Phone:801-377-0037
Mailing Address - Fax:801-377-3141
Practice Address - Street 1:2335 S STATE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6576
Practice Address - Country:US
Practice Address - Phone:801-377-0037
Practice Address - Fax:801-377-3141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49269951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty