Provider Demographics
NPI:1780004267
Name:DR. DOUG'S PEDIATRIC DENTISTRY P.C.
Entity Type:Organization
Organization Name:DR. DOUG'S PEDIATRIC DENTISTRY P.C.
Other - Org Name:SMALL SMILES PEDIATRIC DENTISTRY P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:FRYER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:435-792-3033
Mailing Address - Street 1:1300 N 200 E
Mailing Address - Street 2:SUITE102
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2398
Mailing Address - Country:US
Mailing Address - Phone:435-232-9721
Mailing Address - Fax:435-792-3033
Practice Address - Street 1:1300 N 200 E
Practice Address - Street 2:SUITE102
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2398
Practice Address - Country:US
Practice Address - Phone:435-232-9721
Practice Address - Fax:435-792-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285140-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty