Provider Demographics
NPI:1831696582
Name:SUGARHOUSE DENTAL INC
Entity type:Organization
Organization Name:SUGARHOUSE DENTAL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:KIRKLAND
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-671-6359
Mailing Address - Street 1:620 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1828
Mailing Address - Country:US
Mailing Address - Phone:801-671-6359
Mailing Address - Fax:
Practice Address - Street 1:620 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106
Practice Address - Country:US
Practice Address - Phone:801-671-6359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUGARHOUSE DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-10
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4954595332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment