Provider Demographics
NPI:1568191559
Name:ABUNDANT IMPLANT SERVICES
Entity Type:Organization
Organization Name:ABUNDANT IMPLANT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-550-3901
Mailing Address - Street 1:793 E WINCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7564
Mailing Address - Country:US
Mailing Address - Phone:801-849-1045
Mailing Address - Fax:801-304-3151
Practice Address - Street 1:795 EAST WINCHESTER STREET
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-849-1045
Practice Address - Fax:801-304-3151
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABUNDANT IMPLANT SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty