Provider Demographics
NPI:1558672758
Name:MAIN PLAZA DENTAL
Entity Type:Organization
Organization Name:MAIN PLAZA DENTAL
Other - Org Name:JARED W. HEMMERT
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BRERETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-794-9684
Mailing Address - Street 1:312 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1735
Mailing Address - Country:US
Mailing Address - Phone:801-794-9684
Mailing Address - Fax:801-798-9474
Practice Address - Street 1:312 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1735
Practice Address - Country:US
Practice Address - Phone:801-794-9684
Practice Address - Fax:801-798-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5346167122300000X
UT6947302122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty