Provider Demographics
NPI:1922480144
Name:PREDENTIVE DENTAL COMPANY
Entity Type:Organization
Organization Name:PREDENTIVE DENTAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MBA
Authorized Official - Phone:801-618-0246
Mailing Address - Street 1:6957 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1817
Mailing Address - Country:US
Mailing Address - Phone:801-618-0246
Mailing Address - Fax:
Practice Address - Street 1:6957 S 1300 E
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84047-1817
Practice Address - Country:US
Practice Address - Phone:801-618-0246
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5096414261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental