Healthcare Provider Details

I. General information

NPI: 1841475456
Provider Name (Legal Business Name): HIDDEN VALLEY PEDIATRIC DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E 12450 S STE 200
DRAPER UT
84020-8060
US

IV. Provider business mailing address

114 E 12450 S STE 200
DRAPER UT
84020-8060
US

V. Phone/Fax

Practice location:
  • Phone: 801-495-1610
  • Fax: 801-495-1631
Mailing address:
  • Phone: 801-495-1610
  • Fax: 801-495-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BRENT CARL DEHART
Title or Position: OWNER
Credential: D.D.S.
Phone: 801-495-1610