Healthcare Provider Details

I. General information

NPI: 1992880710
Provider Name (Legal Business Name): PEDIATRIC DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N HIGHWAY 89 #200
FARMINGTON UT
84025-2745
US

IV. Provider business mailing address

1401 N HIGHWAY 89 #200
FARMINGTON UT
84025-2745
US

V. Phone/Fax

Practice location:
  • Phone: 801-447-5437
  • Fax: 801-447-4685
Mailing address:
  • Phone: 801-447-5437
  • Fax: 801-447-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number341292
License Number StateUT

VIII. Authorized Official

Name: DR. JOHN R. ANDERSON
Title or Position: OWNER
Credential:
Phone: 801-540-5081