Healthcare Provider Details

I. General information

NPI: 1598881906
Provider Name (Legal Business Name): EPHRAIM FAMILY DENTAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 E 400 S
EPHRAIM UT
84627-1336
US

IV. Provider business mailing address

35 E 400 S
EPHRAIM UT
84627-1336
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-4081
  • Fax: 435-283-6151
Mailing address:
  • Phone: 435-283-4081
  • Fax: 435-283-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5684051-9922
License Number StateUT

VIII. Authorized Official

Name: DR. WESLEY B THOMPSON
Title or Position: MANAGER
Credential: D.M.D.
Phone: 435-283-4081