Provider Demographics
NPI:1720655194
Name:MOUNTAIN SKY DENTAL LLC
Entity Type:Organization
Organization Name:MOUNTAIN SKY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:385-244-1530
Mailing Address - Street 1:5640 SOUTH WASATCH DR STE A
Mailing Address - Street 2:
Mailing Address - City:SO. OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:385-244-1530
Mailing Address - Fax:385-244-1530
Practice Address - Street 1:5640 SOUTH WASATCH DR STE A
Practice Address - Street 2:
Practice Address - City:SO. OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:385-244-1530
Practice Address - Fax:385-244-1530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN SKY DENTAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty