Provider Demographics
NPI:1851802813
Name:PROVO DOWNTOWN DENTAL, LLC
Entity Type:Organization
Organization Name:PROVO DOWNTOWN DENTAL, LLC
Other - Org Name:PROVO DOWNTOWN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-373-8791
Mailing Address - Street 1:85 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2647
Mailing Address - Country:US
Mailing Address - Phone:801-373-8791
Mailing Address - Fax:
Practice Address - Street 1:85 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-2647
Practice Address - Country:US
Practice Address - Phone:801-373-8791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental