Provider Demographics
NPI:1184706491
Name:PEDIATRIC DENTAL & ORTHODONTICS PC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL & ORTHODONTICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-540-5081
Mailing Address - Street 1:3485 W 4800 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-9429
Mailing Address - Country:US
Mailing Address - Phone:801-774-5437
Mailing Address - Fax:801-774-9440
Practice Address - Street 1:3485 W 4800 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9429
Practice Address - Country:US
Practice Address - Phone:801-774-5437
Practice Address - Fax:801-774-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3412921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528537398001Medicaid