Provider Demographics
NPI:1538679188
Name:ELEVATE ORTHODONTICS LLC
Entity Type:Organization
Organization Name:ELEVATE ORTHODONTICS LLC
Other - Org Name:VINEYARD PEDIATRIC DENTISTRY & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:GOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-382-8820
Mailing Address - Street 1:707 E MILL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-5732
Mailing Address - Country:US
Mailing Address - Phone:801-382-8820
Mailing Address - Fax:385-283-0660
Practice Address - Street 1:707 E MILL RD STE 101
Practice Address - Street 2:
Practice Address - City:VINEYARD
Practice Address - State:UT
Practice Address - Zip Code:84059-5732
Practice Address - Country:US
Practice Address - Phone:801-544-1184
Practice Address - Fax:801-852-0440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty