Provider Demographics
NPI:1629841341
Name:PLAIN CITY FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:PLAIN CITY FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:MORTENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-948-0673
Mailing Address - Street 1:3968 W 5700 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-9176
Mailing Address - Country:US
Mailing Address - Phone:801-376-6494
Mailing Address - Fax:
Practice Address - Street 1:2384 N 4350 W
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:UT
Practice Address - Zip Code:84404-9617
Practice Address - Country:US
Practice Address - Phone:801-948-0673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental