Provider Demographics
NPI:1760819924
Name:GRANDPAS DENTAL CENTER LLC
Entity Type:Organization
Organization Name:GRANDPAS DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELO
Authorized Official - Middle Name:
Authorized Official - Last Name:ABATTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-5200
Mailing Address - Street 1:294 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3858
Mailing Address - Country:US
Mailing Address - Phone:801-374-5200
Mailing Address - Fax:
Practice Address - Street 1:294 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3858
Practice Address - Country:US
Practice Address - Phone:801-374-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental