Provider Demographics
NPI:1457330458
Name:MOUNTAIN RIDGE DENTAL, LLC
Entity Type:Organization
Organization Name:MOUNTAIN RIDGE DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELAHUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-224-7182
Mailing Address - Street 1:1256 S STATE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-8237
Mailing Address - Country:US
Mailing Address - Phone:801-224-7182
Mailing Address - Fax:801-235-0835
Practice Address - Street 1:1256 S STATE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-8237
Practice Address - Country:US
Practice Address - Phone:801-224-7182
Practice Address - Fax:801-235-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty