Provider Demographics
NPI:1851913057
Name:RIDGE PARK DENTAL
Entity Type:Organization
Organization Name:RIDGE PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-773-5285
Mailing Address - Street 1:2307 N HILL FIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6890
Mailing Address - Country:US
Mailing Address - Phone:801-773-5285
Mailing Address - Fax:801-773-2850
Practice Address - Street 1:2307 N HILL FIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6890
Practice Address - Country:US
Practice Address - Phone:801-773-5285
Practice Address - Fax:801-773-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental