Provider Demographics
NPI:1629119409
Name:YOUNGFAMILYDENTALAF
Entity Type:Organization
Organization Name:YOUNGFAMILYDENTALAF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-756-7173
Mailing Address - Street 1:483 E 200 S
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-6279
Mailing Address - Country:US
Mailing Address - Phone:801-756-7173
Mailing Address - Fax:801-756-4577
Practice Address - Street 1:483 E 200 S
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2503
Practice Address - Country:US
Practice Address - Phone:801-756-7173
Practice Address - Fax:801-756-4577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNG FAMILY DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4766943-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty