Provider Demographics
NPI:1619278785
Name:DENTISTRY FOR CHILDREN SANDY PC
Entity Type:Organization
Organization Name:DENTISTRY FOR CHILDREN SANDY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-562-2222
Mailing Address - Street 1:10011 CENTENNIAL PKWY STE 250
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4121
Mailing Address - Country:US
Mailing Address - Phone:801-562-2222
Mailing Address - Fax:801-562-2230
Practice Address - Street 1:10011 CENTENNIAL PKWY STE 250
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4121
Practice Address - Country:US
Practice Address - Phone:801-562-2222
Practice Address - Fax:801-562-2230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5247754261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529313580001Medicaid