Provider Demographics
NPI:1679182612
Name:LIBERTY MOUNTAIN DENTAL LLC
Entity Type:Organization
Organization Name:LIBERTY MOUNTAIN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OWNER (CEO)
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:LINDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-440-5520
Mailing Address - Street 1:1860 N 40 E
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-2235
Mailing Address - Country:US
Mailing Address - Phone:801-440-5520
Mailing Address - Fax:
Practice Address - Street 1:6351 W 13400 S STE 100
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5601
Practice Address - Country:US
Practice Address - Phone:385-237-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty