Provider Demographics
NPI:1558978650
Name:CANDID UTAH, P.C.
Entity Type:Organization
Organization Name:CANDID UTAH, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-481-7631
Mailing Address - Street 1:12884 S FRONTRUNNER BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5488
Mailing Address - Country:US
Mailing Address - Phone:860-481-7631
Mailing Address - Fax:
Practice Address - Street 1:12884 S FRONTRUNNER BLVD STE 140
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5488
Practice Address - Country:US
Practice Address - Phone:860-481-7631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty