Provider Demographics
NPI:1639479488
Name:WASATCH DENTAL ASSOCIATION, P.C.
Entity Type:Organization
Organization Name:WASATCH DENTAL ASSOCIATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-394-0401
Mailing Address - Street 1:1245 CAPITOL ST
Mailing Address - Street 2:SUITE 106-S
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2847
Mailing Address - Country:US
Mailing Address - Phone:801-394-0401
Mailing Address - Fax:801-394-0644
Practice Address - Street 1:1245 CAPITOL ST
Practice Address - Street 2:SUITE 106-S
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2847
Practice Address - Country:US
Practice Address - Phone:801-394-0401
Practice Address - Fax:801-394-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144526261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT518883937000Medicaid