Provider Demographics
NPI:1639828007
Name:PEDOORTHO PARTNERS PLLC
Entity Type:Organization
Organization Name:PEDOORTHO PARTNERS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDNTIALING ,LEAD
Authorized Official - Prefix:
Authorized Official - First Name:VICENTA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:5481 W 7800 S STE 120
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-6027
Mailing Address - Country:US
Mailing Address - Phone:801-542-0817
Mailing Address - Fax:
Practice Address - Street 1:5481 W 7800 S STE 120
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84081-6027
Practice Address - Country:US
Practice Address - Phone:801-542-0817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty