Provider Demographics
NPI:1578748190
Name:DENNIS L DEDECKER DDS PC
Entity Type:Organization
Organization Name:DENNIS L DEDECKER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEDECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-773-9790
Mailing Address - Street 1:2185 N 1700 W
Mailing Address - Street 2:#204
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1192
Mailing Address - Country:US
Mailing Address - Phone:801-773-9790
Mailing Address - Fax:801-773-9792
Practice Address - Street 1:2185 N 1700 W
Practice Address - Street 2:#204
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-1192
Practice Address - Country:US
Practice Address - Phone:801-773-9790
Practice Address - Fax:801-773-9792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT135665 99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107004925101OtherSELECTHEALTH
UT190000851OtherRAILROAD MEDICARE
UT000002181OtherMEDICARE PROVIDER#
UT52970991500001OtherBLUECROSS BLUESHIELD