Healthcare Provider Details

I. General information

NPI: 1972868453
Provider Name (Legal Business Name): COBBLE CREEK DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2274 N 400 E SUITE 204
NORTH OGDEN UT
84414-7378
US

IV. Provider business mailing address

2274 N 400 E SUITE 204
NORTH OGDEN UT
84414-7378
US

V. Phone/Fax

Practice location:
  • Phone: 801-399-0458
  • Fax: 801-393-2212
Mailing address:
  • Phone: 801-399-0458
  • Fax: 801-393-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6822295
License Number StateUT

VIII. Authorized Official

Name: MR. MARK E HARRIS
Title or Position: OWNER / DENTIST
Credential: DDS
Phone: 801-399-0458