Provider Demographics
NPI:1962635466
Name:BULLEN & WILSON EAGLEGATE COLLEGE DENTAL CLINIC
Entity Type:Organization
Organization Name:BULLEN & WILSON EAGLEGATE COLLEGE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLI
Authorized Official - Middle Name:D
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:801-333-8138
Mailing Address - Street 1:5618 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5796
Mailing Address - Country:US
Mailing Address - Phone:801-333-8138
Mailing Address - Fax:801-263-6520
Practice Address - Street 1:5618 GREEN ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5796
Practice Address - Country:US
Practice Address - Phone:801-333-8138
Practice Address - Fax:801-263-6520
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BULLEN & WILSON EAGLEGATE COLLEGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133186-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty