Healthcare Provider Details

I. General information

NPI: 1881962785
Provider Name (Legal Business Name): INTERMOUNTAIN DENTAL ASSOCIATES-ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 N 400 E SUITE 2
NORTH OGDEN UT
84414-2393
US

IV. Provider business mailing address

2721 N 400 E SUITE 2
NORTH OGDEN UT
84414-2393
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-5682
  • Fax: 801-786-0520
Mailing address:
  • Phone: 801-782-5682
  • Fax: 801-786-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number144024
License Number StateUT

VIII. Authorized Official

Name: VICKI LEWIS
Title or Position: SPECIALIST COORDINTOR
Credential:
Phone: 801-782-5682