Provider Demographics
NPI:1558516161
Name:PARK CITY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:PARK CITY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPANY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:COCHRAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-553-8882
Mailing Address - Street 1:1830 PROSPECTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7319
Mailing Address - Country:US
Mailing Address - Phone:801-661-8470
Mailing Address - Fax:
Practice Address - Street 1:1830 PROSPECTOR AVE
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7319
Practice Address - Country:US
Practice Address - Phone:801-661-8470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty