Provider Demographics
NPI:1629436951
Name:INTERMOUNTAIN FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:INTERMOUNTAIN FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-573-4300
Mailing Address - Street 1:2414 W 7800 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4292
Mailing Address - Country:US
Mailing Address - Phone:801-573-4300
Mailing Address - Fax:
Practice Address - Street 1:2414 W 7800 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4292
Practice Address - Country:US
Practice Address - Phone:801-573-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4746306-99221223G0001X
UT5898704-99211223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty