Provider Demographics
NPI:1710545769
Name:SCHWEPPE PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:SCHWEPPE PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCHWEPPE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-479-9220
Mailing Address - Street 1:5685 S 1475 E STE 3A
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4598
Mailing Address - Country:US
Mailing Address - Phone:801-479-9220
Mailing Address - Fax:801-479-0837
Practice Address - Street 1:5685 S 1475 E STE 3A
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4598
Practice Address - Country:US
Practice Address - Phone:801-479-9220
Practice Address - Fax:801-479-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1141007-00Medicaid
UT517747532013Medicaid