Provider Demographics
NPI:1710292339
Name:MOUNTAIN VISTA DENTAL CARE
Entity Type:Organization
Organization Name:MOUNTAIN VISTA DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:MCCONKIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-786-0700
Mailing Address - Street 1:539 N HARRISVILLE RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3560
Mailing Address - Country:US
Mailing Address - Phone:801-786-0700
Mailing Address - Fax:801-340-5025
Practice Address - Street 1:539 N HARRISVILLE RD
Practice Address - Street 2:SUITE F
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-3560
Practice Address - Country:US
Practice Address - Phone:801-786-0700
Practice Address - Fax:801-340-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51678011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty