Provider Demographics
NPI:1013338912
Name:LONE PEAK PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:LONE PEAK PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-918-4135
Mailing Address - Street 1:1030 E 11400 S
Mailing Address - Street 2:SUITE #101
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-6902
Mailing Address - Country:US
Mailing Address - Phone:801-553-8882
Mailing Address - Fax:801-553-8883
Practice Address - Street 1:1030 E 11400 S
Practice Address - Street 2:SUITE #101
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-6902
Practice Address - Country:US
Practice Address - Phone:801-553-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental