Provider Demographics
NPI:1922609015
Name:CORNER CLINIC DENTAL STG
Entity Type:Organization
Organization Name:CORNER CLINIC DENTAL STG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HEYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-671-3285
Mailing Address - Street 1:380 E MAIN ST BLDG B2ND
Mailing Address - Street 2:
Mailing Address - City:MIDWAY
Mailing Address - State:UT
Mailing Address - Zip Code:84049-6801
Mailing Address - Country:US
Mailing Address - Phone:435-659-7352
Mailing Address - Fax:
Practice Address - Street 1:2351 S RIVER RD STE 4
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8749
Practice Address - Country:US
Practice Address - Phone:435-709-8786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental