Provider Demographics
NPI:1336576818
Name:IVERSON DENTAL, INC.
Entity Type:Organization
Organization Name:IVERSON DENTAL, INC.
Other - Org Name:IVERSON DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VERN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-745-3882
Mailing Address - Street 1:PO BOX 900
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-0900
Mailing Address - Country:US
Mailing Address - Phone:801-745-3882
Mailing Address - Fax:801-745-6207
Practice Address - Street 1:2627 N HIGHWAY 162
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310-9745
Practice Address - Country:US
Practice Address - Phone:801-745-3882
Practice Address - Fax:801-745-6207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1338754-01421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1487617940Medicaid