Healthcare Provider Details

I. General information

NPI: 1073924098
Provider Name (Legal Business Name): STONEHAVEN DENTAL - OREM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 05/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 N STATE ST
OREM UT
84057-2027
US

IV. Provider business mailing address

PO BOX 437169
LOUISVILLE KY
40253-7169
US

V. Phone/Fax

Practice location:
  • Phone: 801-766-3600
  • Fax:
Mailing address:
  • Phone: 502-254-8501
  • 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: STEVE JAMES
Title or Position: CFO
Credential:
Phone: 502-254-8504