Provider Demographics
NPI:1598033409
Name:INTERMOUNTAIN DENTAL ASSOCIATES - SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:INTERMOUNTAIN DENTAL ASSOCIATES - SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIALIST COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-782-5682
Mailing Address - Street 1:2721 N 400 E
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2393
Mailing Address - Country:US
Mailing Address - Phone:801-782-5682
Mailing Address - Fax:801-786-0520
Practice Address - Street 1:2721 N 400 E
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-2393
Practice Address - Country:US
Practice Address - Phone:801-782-5682
Practice Address - Fax:801-786-0520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERMOUNTAIN DENTAL ASSOCIATES SPECIALTY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144024-99221223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty