Provider Demographics
NPI:1821521485
Name:KIDS CREEK PED. DENTISTRY
Entity Type:Organization
Organization Name:KIDS CREEK PED. DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-417-8080
Mailing Address - Street 1:2964 W 4700 S STE 103
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-2558
Mailing Address - Country:US
Mailing Address - Phone:801-417-8080
Mailing Address - Fax:
Practice Address - Street 1:2964 W 4700 S STE 103
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2558
Practice Address - Country:US
Practice Address - Phone:801-417-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT76936531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty