Provider Demographics
NPI:1972822930
Name:ABC PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:ABC PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-842-6971
Mailing Address - Street 1:4019 W 12600 S STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7406
Mailing Address - Country:US
Mailing Address - Phone:801-842-6971
Mailing Address - Fax:
Practice Address - Street 1:610 S 4J CT # B
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4127
Practice Address - Country:US
Practice Address - Phone:801-842-6971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty