Healthcare Provider Details

I. General information

NPI: 1962609644
Provider Name (Legal Business Name): VINE STREET PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 E VINE ST SUITE #12
MURRAY UT
84107-5546
US

IV. Provider business mailing address

678 E VINE ST SUITE #12
MURRAY UT
84107-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-1135
  • Fax: 801-685-7630
Mailing address:
  • Phone: 801-268-1135
  • Fax: 801-685-7630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-268-1135