Provider Demographics
NPI:1689300360
Name:STATION PARK PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:STATION PARK PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-278-6749
Mailing Address - Street 1:1195 WEST PARK LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025
Mailing Address - Country:US
Mailing Address - Phone:801-882-8800
Mailing Address - Fax:
Practice Address - Street 1:1195 WEST PARK LN
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025
Practice Address - Country:US
Practice Address - Phone:801-882-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1770712838Medicaid