Provider Demographics
NPI:1255776431
Name:BONNEVILLE PREVENTIVE DENTISTRY PLLC
Entity type:Organization
Organization Name:BONNEVILLE PREVENTIVE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLPERT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-627-0420
Mailing Address - Street 1:3860 JACKSON AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1956
Mailing Address - Country:US
Mailing Address - Phone:801-627-0420
Mailing Address - Fax:
Practice Address - Street 1:3860 JACKSON AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1956
Practice Address - Country:US
Practice Address - Phone:801-627-0420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8289908261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental