Provider Demographics
NPI:1982721114
Name:FAMILY LEGACY DENTAL, LLC
Entity Type:Organization
Organization Name:FAMILY LEGACY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAMONA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-227-5080
Mailing Address - Street 1:845 N 100 W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3180
Mailing Address - Country:US
Mailing Address - Phone:801-227-5080
Mailing Address - Fax:
Practice Address - Street 1:845 N 100 W
Practice Address - Street 2:SUITE 100
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3180
Practice Address - Country:US
Practice Address - Phone:801-227-5080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5672963-01601223G0001X, 1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT363064330001Medicaid
UT475132674001Medicaid
UT529361668001Medicaid
UT529779405001Medicaid
UT529636043001Medicaid