Provider Demographics
NPI:1760144117
Name:PARK CITY DENTAL SPA
Entity Type:Organization
Organization Name:PARK CITY DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAWNETTA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:435-615-8500
Mailing Address - Street 1:1526 UTE BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-7654
Mailing Address - Country:US
Mailing Address - Phone:435-615-8500
Mailing Address - Fax:
Practice Address - Street 1:1526 UTE BLVD STE 212
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7654
Practice Address - Country:US
Practice Address - Phone:435-615-8500
Practice Address - Fax:435-214-7246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental