Provider Demographics
NPI:1831338623
Name:ROSE PARK PEDIATRIC DENTISTRY, PC
Entity type:Organization
Organization Name:ROSE PARK PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-519-2222
Mailing Address - Street 1:55 N REDWOOD RD STE B
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3174
Mailing Address - Country:US
Mailing Address - Phone:801-519-2222
Mailing Address - Fax:
Practice Address - Street 1:55 N REDWOOD RD STE B
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3174
Practice Address - Country:US
Practice Address - Phone:801-519-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:49534949923
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT495349499231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty