Provider Demographics
NPI:1598162141
Name:MODERN DENTAL PROFESSIONALS - UTAH, PC
Entity Type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS - UTAH, PC
Other - Org Name:MONARCH DENTAL - BOUNTIFUL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-308-9792
Mailing Address - Street 1:8415 DATAPOINT DR STE 1020
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3277
Mailing Address - Country:US
Mailing Address - Phone:210-929-2814
Mailing Address - Fax:210-615-3626
Practice Address - Street 1:24 SOUTH 500 WEST, #D
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-296-1606
Practice Address - Fax:801-396-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-25
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty