Provider Demographics
NPI:1508236795
Name:FOREVER YOUNG DENTISTRY PLLC
Entity Type:Organization
Organization Name:FOREVER YOUNG DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REYNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADRILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-225-1630
Mailing Address - Street 1:2335 S. STATE STREET
Mailing Address - Street 2:STE #200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606
Mailing Address - Country:US
Mailing Address - Phone:801-225-1630
Mailing Address - Fax:801-404-5802
Practice Address - Street 1:2335 S. STATE STREET
Practice Address - Street 2:STE #200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606
Practice Address - Country:US
Practice Address - Phone:801-225-1630
Practice Address - Fax:801-225-1630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOREVER YOUNG DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT564618729-001Medicaid