Healthcare Provider Details

I. General information

NPI: 1669928909
Provider Name (Legal Business Name): JORDAN RIDGE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

678 E. VINE STREET SUITE #10
MURRAY UT
84107
US

IV. Provider business mailing address

678 E VINE ST SUITE #10
MURRAY UT
84107-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-918-4135
  • Fax:
Mailing address:
  • Phone: 801-918-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCI NICOL
Title or Position: VP OF OPERATIONS
Credential:
Phone: 801-918-4135