Healthcare Provider Details

I. General information

NPI: 1275859589
Provider Name (Legal Business Name): LEGACY FAMILY DENTAL OF BOUNTIFUL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 E 2200 S
BOUNTIFUL UT
84010-5619
US

IV. Provider business mailing address

55 E 2200 S
BOUNTIFUL UT
84010-5619
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-5115
  • Fax: 801-397-5559
Mailing address:
  • Phone: 801-295-5115
  • Fax: 801-397-5559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number75313980160
License Number StateUT

VIII. Authorized Official

Name: MR. KASE PEERY
Title or Position: OWNER/MANAGING MEMBER
Credential:
Phone: 801-870-0838