Provider Demographics
NPI:1578972592
Name:I SMILE AT CROSSROADS DENTAL GROUP
Entity Type:Organization
Organization Name:I SMILE AT CROSSROADS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LARA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-561-1559
Mailing Address - Street 1:3409 W 12600 S
Mailing Address - Street 2:100
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3409 W 12600 S
Practice Address - Street 2:100
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7260
Practice Address - Country:US
Practice Address - Phone:801-561-1559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty