Provider Demographics
NPI:1568906824
Name:MSG DENTAL LLC
Entity Type:Organization
Organization Name:MSG DENTAL LLC
Other - Org Name:COUGAR DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORBIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MATTHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-473-6455
Mailing Address - Street 1:835 N 700 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-6993
Mailing Address - Country:US
Mailing Address - Phone:801-373-7700
Mailing Address - Fax:801-370-0762
Practice Address - Street 1:835 N 700 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6993
Practice Address - Country:US
Practice Address - Phone:801-373-7700
Practice Address - Fax:801-370-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT372923261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental