Provider Demographics
NPI:1629808779
Name:PIINNACLE DENTAL PARRTNERS
Entity type:Organization
Organization Name:PIINNACLE DENTAL PARRTNERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:TANUVASA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-216-4421
Mailing Address - Street 1:516 W PALO VERDE WAY
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738-1207
Mailing Address - Country:US
Mailing Address - Phone:385-216-4421
Mailing Address - Fax:
Practice Address - Street 1:533 W STATE RD STE 201
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2116
Practice Address - Country:US
Practice Address - Phone:385-216-4421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINNACLE DENTAL PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty