Provider Demographics
NPI:1518209659
Name:LEGACY DENTAL
Entity Type:Organization
Organization Name:LEGACY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:GALEN
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-278-4223
Mailing Address - Street 1:1345 E 3900 S STE 116
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4407
Mailing Address - Country:US
Mailing Address - Phone:801-278-4223
Mailing Address - Fax:801-278-2628
Practice Address - Street 1:1345 E 3900 S STE 116
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4407
Practice Address - Country:US
Practice Address - Phone:801-278-4223
Practice Address - Fax:801-278-2628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT373764-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty