Healthcare Provider Details

I. General information

NPI: 1023320728
Provider Name (Legal Business Name): CHILDREN'S CORNER PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W 200 N STE 175
LINDON UT
84042-5009
US

IV. Provider business mailing address

275 W 200 N STE 175
LINDON UT
84042-5009
US

V. Phone/Fax

Practice location:
  • Phone: 801-769-2530
  • Fax: 801-769-2531
Mailing address:
  • Phone: 801-769-2530
  • Fax: 801-769-2531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7108173
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. STUART D SEGURA
Title or Position: PARTNER
Credential: D.D.S., M.S.D.
Phone: 801-769-2530