Provider Demographics
NPI:1982107306
Name:RIDGE PARK DENTAL
Entity Type:Organization
Organization Name:RIDGE PARK DENTAL
Other - Org Name:DR. GRANT A. BROUGH, DDS, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:ATWOOD
Authorized Official - Last Name:BROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-773-5285
Mailing Address - Street 1:2307 N HILL FIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6890
Mailing Address - Country:US
Mailing Address - Phone:801-773-5285
Mailing Address - Fax:801-773-2850
Practice Address - Street 1:2307 N HILL FIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6890
Practice Address - Country:US
Practice Address - Phone:801-773-5285
Practice Address - Fax:801-773-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2752321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty