Provider Demographics
NPI:1184320293
Name:PROVO PEDIATRIC DENTAL
Entity type:Organization
Organization Name:PROVO PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-9590
Mailing Address - Street 1:391 N 400 E
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-2537
Mailing Address - Country:US
Mailing Address - Phone:435-637-9590
Mailing Address - Fax:435-637-2228
Practice Address - Street 1:745 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1472
Practice Address - Country:US
Practice Address - Phone:801-373-4200
Practice Address - Fax:801-373-0816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1811446727OtherTYPE 1 NPI
UT1912072620OtherTYPE 1 NPI
UT1598830291OtherTYPE 1 NPI