Provider Demographics
NPI:1881069177
Name:INTERMOUNTAIN DENTAL SPECIALISTS
Entity type:Organization
Organization Name:INTERMOUNTAIN DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIALIST COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-782-5682
Mailing Address - Street 1:2797 N HIGHWAY 89
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84404-1216
Mailing Address - Country:US
Mailing Address - Phone:801-782-5682
Mailing Address - Fax:801-786-0520
Practice Address - Street 1:2797 N HIGHWAY 89
Practice Address - Street 2:SUITE 200
Practice Address - City:PLEASANT VIEW
Practice Address - State:UT
Practice Address - Zip Code:84404-1216
Practice Address - Country:US
Practice Address - Phone:801-782-5682
Practice Address - Fax:801-786-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145326-99221223E0200X
UT145288-99221223E0200X
UT137712-99221223P0300X
UT8598613-99241223S0112X
UT9371431-99211223X0400X
UT80414581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty