Provider Demographics
NPI:1821382342
Name:NEIBAUR FAMILY ORTHODONTICS LLC
Entity type:Organization
Organization Name:NEIBAUR FAMILY ORTHODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEIBAUR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-269-0303
Mailing Address - Street 1:6095 FASHION BLVD
Mailing Address - Street 2:STE 210
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7397
Mailing Address - Country:US
Mailing Address - Phone:801-269-0303
Mailing Address - Fax:801-269-0447
Practice Address - Street 1:6095 FASHION BLVD
Practice Address - Street 2:STE 210
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7397
Practice Address - Country:US
Practice Address - Phone:801-269-0303
Practice Address - Fax:801-269-0447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4990210-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty