Provider Demographics
NPI:1851607402
Name:ELITE DENTAL
Entity Type:Organization
Organization Name:ELITE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-969-2121
Mailing Address - Street 1:3280 W 3500 S #3
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3280 W 3500 S
Practice Address - Street 2:#3
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-2668
Practice Address - Country:US
Practice Address - Phone:801-969-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT69371998903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty