Provider Demographics
NPI:1467880716
Name:TRAVERSE MOUNTAIN FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:TRAVERSE MOUNTAIN FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:F
Authorized Official - Last Name:STAPLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-852-8211
Mailing Address - Street 1:3940 TRAVERSE MOUNTAIN BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4914
Mailing Address - Country:US
Mailing Address - Phone:801-852-8211
Mailing Address - Fax:801-901-1923
Practice Address - Street 1:3940 TRAVERSE MOUNTAIN BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4914
Practice Address - Country:US
Practice Address - Phone:801-852-8211
Practice Address - Fax:801-901-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8291219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty