Provider Demographics
NPI:1265984660
Name:ADVANCED DENTAL PC
Entity type:Organization
Organization Name:ADVANCED DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHINER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-828-4099
Mailing Address - Street 1:1272 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2925
Mailing Address - Country:US
Mailing Address - Phone:435-781-0660
Mailing Address - Fax:435-781-0661
Practice Address - Street 1:1272 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2925
Practice Address - Country:US
Practice Address - Phone:435-781-0660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6712357-9923332BC3200X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty