Provider Demographics
NPI:1528374337
Name:JORDAN LANDING PEDIATRICS
Entity Type:Organization
Organization Name:JORDAN LANDING PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:R
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-280-9595
Mailing Address - Street 1:7613 JORDAN LANDING BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-1972
Mailing Address - Country:US
Mailing Address - Phone:801-280-9595
Mailing Address - Fax:801-280-1169
Practice Address - Street 1:7613 JORDAN LANDING BLVD
Practice Address - Street 2:STE 210
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1972
Practice Address - Country:US
Practice Address - Phone:801-280-9595
Practice Address - Fax:801-280-1169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002204002Medicaid
UT528451522009Medicaid