Provider Demographics
NPI:1891101572
Name:CHILDREN'S DENTAL OF SOUTHERN UTAH
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL OF SOUTHERN UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:SCHOLZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-673-7776
Mailing Address - Street 1:201 S 700 W
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-2423
Mailing Address - Country:US
Mailing Address - Phone:435-673-7776
Mailing Address - Fax:435-627-2592
Practice Address - Street 1:2746 E 850 N
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5839
Practice Address - Country:US
Practice Address - Phone:435-673-7776
Practice Address - Fax:435-627-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6329558-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty