Provider Demographics
NPI:1700071024
Name:DINOSAURLAND PEDIATRICS
Entity Type:Organization
Organization Name:DINOSAURLAND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-789-9060
Mailing Address - Street 1:175 N 100 W
Mailing Address - Street 2:STE 106
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 N 100 W
Practice Address - Street 2:STE 106
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2049
Practice Address - Country:US
Practice Address - Phone:435-789-9060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty