Provider Demographics
NPI:1972926111
Name:ISMILE AT KAYSVILLE LLC
Entity Type:Organization
Organization Name:ISMILE AT KAYSVILLE LLC
Other - Org Name:PROGRESSIVE DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:G
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-544-3953
Mailing Address - Street 1:302 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-6766
Mailing Address - Country:US
Mailing Address - Phone:801-544-3953
Mailing Address - Fax:801-660-1312
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-6766
Practice Address - Country:US
Practice Address - Phone:801-544-3953
Practice Address - Fax:801-660-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT53102631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty