Provider Demographics
NPI:1467588004
Name:PITT FAMILY DENTAL
Entity Type:Organization
Organization Name:PITT FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:PITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-295-6192
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:281 SOUTH MAIN
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014
Mailing Address - Country:US
Mailing Address - Phone:801-295-6192
Mailing Address - Fax:801-295-6011
Practice Address - Street 1:281 SOUTH MAIN
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014
Practice Address - Country:US
Practice Address - Phone:801-295-6192
Practice Address - Fax:801-295-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1344871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529566754005Medicaid