Provider Demographics
NPI:1639654684
Name:CLUBHOUSE PEDIATRIC DENTISTRY OF WEST JORDAN
Entity Type:Organization
Organization Name:CLUBHOUSE PEDIATRIC DENTISTRY OF WEST JORDAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-520-1514
Mailing Address - Street 1:1108 E SOUTH UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2904
Mailing Address - Country:US
Mailing Address - Phone:208-520-1514
Mailing Address - Fax:
Practice Address - Street 1:1108 E SOUTH UNION AVE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2904
Practice Address - Country:US
Practice Address - Phone:208-520-1514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPSTONE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty