Provider Demographics
NPI:1679754766
Name:STANSBURY PEDIATRIC DENTISTRY AND ORTHODONTICS
Entity Type:Organization
Organization Name:STANSBURY PEDIATRIC DENTISTRY AND ORTHODONTICS
Other - Org Name:DENTISTRY 4 THE KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-840-1025
Mailing Address - Street 1:PO BOX 1249
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1249
Mailing Address - Country:US
Mailing Address - Phone:435-840-1025
Mailing Address - Fax:435-882-2680
Practice Address - Street 1:220 MILLPOND
Practice Address - Street 2:SUITE #106
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9745
Practice Address - Country:US
Practice Address - Phone:435-840-1025
Practice Address - Fax:435-882-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-17
Last Update Date:2007-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4753208-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT296664784000Medicaid