Provider Demographics
NPI:1962609644
Name:VINE STREET PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:VINE STREET PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-268-1135
Mailing Address - Street 1:678 E VINE ST
Mailing Address - Street 2:SUITE #12
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5546
Mailing Address - Country:US
Mailing Address - Phone:801-268-1135
Mailing Address - Fax:801-685-7630
Practice Address - Street 1:678 E VINE ST
Practice Address - Street 2:SUITE #12
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5546
Practice Address - Country:US
Practice Address - Phone:801-268-1135
Practice Address - Fax:801-685-7630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty