Provider Demographics
NPI:1578196861
Name:FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-317-8555
Mailing Address - Street 1:10597 S BEACH COMBER WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-6132
Mailing Address - Country:US
Mailing Address - Phone:208-317-8555
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST # 404
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-4747
Practice Address - Fax:385-646-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1679841811Medicaid