Provider Demographics
NPI:1508435280
Name:AMIGOS DENTAL CARE- MARMALADE DISTRICT, LLC
Entity Type:Organization
Organization Name:AMIGOS DENTAL CARE- MARMALADE DISTRICT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-326-8004
Mailing Address - Street 1:333 N 300 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-1215
Mailing Address - Country:US
Mailing Address - Phone:801-419-0304
Mailing Address - Fax:
Practice Address - Street 1:333 N 300 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-1215
Practice Address - Country:US
Practice Address - Phone:801-419-0304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental