Provider Demographics
NPI:1811269756
Name:PACIFIC WEST DENTAL GROUP
Entity type:Organization
Organization Name:PACIFIC WEST DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-614-0099
Mailing Address - Street 1:1792 W 1700 S STE 101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9650
Mailing Address - Country:US
Mailing Address - Phone:801-614-0099
Mailing Address - Fax:801-776-3661
Practice Address - Street 1:1792 W 1700 S STE 101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9650
Practice Address - Country:US
Practice Address - Phone:801-614-0099
Practice Address - Fax:801-776-3661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-08
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49210681223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty