Provider Demographics
NPI:1518641083
Name:LAKE MOUNTAIN DENTAL EAGLE MOUNTAIN LLC
Entity Type:Organization
Organization Name:LAKE MOUNTAIN DENTAL EAGLE MOUNTAIN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CADEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CADEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-830-4486
Mailing Address - Street 1:4342 E PONY EXPRESS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-5773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4342 E PONY EXPRESS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5773
Practice Address - Country:US
Practice Address - Phone:801-830-4486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty