Provider Demographics
NPI:1841568243
Name:SOUTH OGDEN DENTAL PC
Entity Type:Organization
Organization Name:SOUTH OGDEN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-479-3500
Mailing Address - Street 1:5738 S 1475 E STE 200
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4859
Mailing Address - Country:US
Mailing Address - Phone:801-479-3500
Mailing Address - Fax:801-479-1600
Practice Address - Street 1:5738 S 1475 E STE 200
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4859
Practice Address - Country:US
Practice Address - Phone:801-479-3500
Practice Address - Fax:801-479-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2763061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52937685101001Medicaid