Provider Demographics
NPI:1619551496
Name:PROFESSIONAL DENTAL CIRCLEVILLE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL CIRCLEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-785-8000
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1806
Mailing Address - Country:US
Mailing Address - Phone:801-785-8000
Mailing Address - Fax:
Practice Address - Street 1:110 SOUTH 100 EAST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:UT
Practice Address - Zip Code:84723
Practice Address - Country:US
Practice Address - Phone:801-785-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-08
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1942396643OtherNPI