Provider Demographics
NPI:1851538862
Name:SALT LAKE DONATED DENTAL SERVICES
Entity Type:Organization
Organization Name:SALT LAKE DONATED DENTAL SERVICES
Other - Org Name:SLDDS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-983-0351
Mailing Address - Street 1:1383 S 900 W
Mailing Address - Street 2:SUITE 128
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-1603
Mailing Address - Country:US
Mailing Address - Phone:801-983-0350
Mailing Address - Fax:
Practice Address - Street 1:1383 S 900 W
Practice Address - Street 2:SUITE 128
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-1603
Practice Address - Country:US
Practice Address - Phone:801-983-0350
Practice Address - Fax:801-983-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-13
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870422710002Medicaid