Provider Demographics
NPI:1922211523
Name:SMALL SMILES PEDIATRIC DENTISTRY P.C.
Entity Type:Organization
Organization Name:SMALL SMILES PEDIATRIC DENTISTRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FRYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-792-3033
Mailing Address - Street 1:1300 N 200 E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2398
Mailing Address - Country:US
Mailing Address - Phone:435-792-3033
Mailing Address - Fax:435-792-3233
Practice Address - Street 1:1300 N 200 E
Practice Address - Street 2:SUITE 102
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2398
Practice Address - Country:US
Practice Address - Phone:435-792-3033
Practice Address - Fax:435-792-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT285140-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529376727002Medicaid