Provider Demographics
NPI:1578928172
Name:SUGAR HOUSE DENTAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:SUGAR HOUSE DENTAL MANAGEMENT LLC
Other - Org Name:THE SUGAR HOUSE DENTIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:THEURER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-486-9649
Mailing Address - Street 1:1955 S 1300 E STE L2
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3675
Mailing Address - Country:US
Mailing Address - Phone:801-486-9649
Mailing Address - Fax:801-486-9640
Practice Address - Street 1:1955 S 1300 E STE L2
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3675
Practice Address - Country:US
Practice Address - Phone:801-486-9649
Practice Address - Fax:801-486-9640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-23
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
UT9361973305R00000X
UT337770305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1700897428OtherNPI
UT1023423258OtherNPI