Provider Demographics
NPI:1609566538
Name:MDG - NEPHI DENTAL, LLC
Entity Type:Organization
Organization Name:MDG - NEPHI DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLEY
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:HERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-726-6836
Mailing Address - Street 1:490 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1102
Mailing Address - Country:US
Mailing Address - Phone:435-623-1918
Mailing Address - Fax:
Practice Address - Street 1:490 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NEPHI
Practice Address - State:UT
Practice Address - Zip Code:84648-1102
Practice Address - Country:US
Practice Address - Phone:435-623-1918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental