Provider Demographics
NPI:1992179964
Name:KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE
Entity Type:Organization
Organization Name:KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:PACKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-217-3359
Mailing Address - Street 1:780 S 2000 W
Mailing Address - Street 2:SUITE #F-2
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9602
Mailing Address - Country:US
Mailing Address - Phone:801-776-8176
Mailing Address - Fax:801-774-9085
Practice Address - Street 1:780 S 2000 W
Practice Address - Street 2:SUITE #F-2
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9602
Practice Address - Country:US
Practice Address - Phone:801-776-8176
Practice Address - Fax:801-774-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6362621-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1477728269Medicaid