MEDICARE: STONEHAVEN DENTAL - EAGLE MOUNTAIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1457828147
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONEHAVEN DENTAL - EAGLE MOUNTAIN

Provider Business Mailing Address
First Line	:	PO BOX 437169
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40253-7169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3566 E PONY EXPRESS PKWY STE 1
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-5680
Country	:	US
Telephone Number	:	502-254-8500
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JEFF REIBEL
Credential	:
Telephone Number	:	502-254-8500

Provider Enumeration Date	:	10/31/2018
Last Update Date	:	09/05/2023

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