Provider Demographics
NPI:1457767840
Name:CHILDREN'S DENTAL OF CEDAR CITY
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL OF CEDAR CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JACK
Authorized Official - Last Name:SCHOLZEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-586-6555
Mailing Address - Street 1:201 S 700 W
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-2423
Mailing Address - Country:US
Mailing Address - Phone:435-586-6555
Mailing Address - Fax:435-586-6602
Practice Address - Street 1:1321 S PROVIDENCE CENTER DR
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-7985
Practice Address - Country:US
Practice Address - Phone:435-586-6555
Practice Address - Fax:435-586-6602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6329558-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty