Provider Demographics
NPI:1669842647
Name:CENTER SQUARE FAMILY DENTAL, PLLC
Entity Type:Organization
Organization Name:CENTER SQUARE FAMILY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ALCORN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-255-4821
Mailing Address - Street 1:7679 S CENTER SQ
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7329
Mailing Address - Country:US
Mailing Address - Phone:801-255-4821
Mailing Address - Fax:801-566-8143
Practice Address - Street 1:7679 S CENTER SQ
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7329
Practice Address - Country:US
Practice Address - Phone:801-255-4821
Practice Address - Fax:801-566-8143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53298821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty