Provider Demographics
NPI:1982155909
Name:MSG DENTAL LLC
Entity Type:Organization
Organization Name:MSG DENTAL LLC
Other - Org Name:COUGAR DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:C
Authorized Official - Last Name:GROESBECK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-373-7700
Mailing Address - Street 1:835 N 700 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-6993
Mailing Address - Country:US
Mailing Address - Phone:801-373-7700
Mailing Address - Fax:
Practice Address - Street 1:835 N 700 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6993
Practice Address - Country:US
Practice Address - Phone:801-373-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8372408-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty