Healthcare Provider Details

I. General information

NPI: 1558516161
Provider Name (Legal Business Name): PARK CITY PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 PROSPECTOR AVE
PARK CITY UT
84060-7319
US

IV. Provider business mailing address

1830 PROSPECTOR AVE
PARK CITY UT
84060-7319
US

V. Phone/Fax

Practice location:
  • Phone: 801-661-8470
  • Fax:
Mailing address:
  • Phone: 801-661-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TINA COCHRAN
Title or Position: COMPANY COORDINATOR
Credential:
Phone: 801-553-8882