Provider Demographics
NPI:1922440031
Name:HYDE PARK DENTAL
Entity Type:Organization
Organization Name:HYDE PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:LAMARR
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-787-4444
Mailing Address - Street 1:3125 N MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1547
Mailing Address - Country:US
Mailing Address - Phone:435-787-4444
Mailing Address - Fax:435-787-0044
Practice Address - Street 1:3125 N MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1547
Practice Address - Country:US
Practice Address - Phone:435-787-4444
Practice Address - Fax:435-787-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14338299221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty