Provider Demographics
NPI:1972783017
Name:MT. OGDEN DENTAL CLINIC, INC.
Entity Type:Organization
Organization Name:MT. OGDEN DENTAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:COOK
Authorized Official - Last Name:GEDDES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-394-4415
Mailing Address - Street 1:1220 33RD ST STE B
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1381
Mailing Address - Country:US
Mailing Address - Phone:801-394-4415
Mailing Address - Fax:801-394-3212
Practice Address - Street 1:1220 33RD ST STE B
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1381
Practice Address - Country:US
Practice Address - Phone:801-394-4415
Practice Address - Fax:801-394-3212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5145132-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty