Provider Demographics
NPI:1497168975
Name:PROVO DENTAL CARE LLC
Entity Type:Organization
Organization Name:PROVO DENTAL CARE LLC
Other - Org Name:STONEHAVEN DENTAL - PROVO, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8504
Mailing Address - Street 1:PO BOX 437169
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-7169
Mailing Address - Country:US
Mailing Address - Phone:502-254-8501
Mailing Address - Fax:
Practice Address - Street 1:1355 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-874-2451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental