Provider Demographics
NPI:1669004586
Name:RIVERTON FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:RIVERTON FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DILLON
Authorized Official - Middle Name:WILLES
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-824-2642
Mailing Address - Street 1:2464 W 12600 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7274
Mailing Address - Country:US
Mailing Address - Phone:801-446-8446
Mailing Address - Fax:
Practice Address - Street 1:2464 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7274
Practice Address - Country:US
Practice Address - Phone:801-446-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty