Provider Demographics
NPI:1770526873
Name:ARBUCKLE DENTAL PC
Entity type:Organization
Organization Name:ARBUCKLE DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:ARBUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-292-0733
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-5088
Mailing Address - Country:US
Mailing Address - Phone:801-292-0733
Mailing Address - Fax:801-298-5336
Practice Address - Street 1:281 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2378
Practice Address - Country:US
Practice Address - Phone:801-292-0733
Practice Address - Fax:801-298-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1770526873Medicaid
UT528446804006Medicaid
UT529295479001Medicaid
UT529196351001Medicaid