Healthcare Provider Details

I. General information

NPI: 1760819924
Provider Name (Legal Business Name): GRANDPAS DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

294 W 800 N
OREM UT
84057-3858
US

IV. Provider business mailing address

294 W 800 N
OREM UT
84057-3858
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-5200
  • Fax:
Mailing address:
  • Phone: 801-374-5200
  • 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: MARCELO ABATTI
Title or Position: MEMBER
Credential:
Phone: 801-374-5200