Healthcare Provider Details

I. General information

NPI: 1508287475
Provider Name (Legal Business Name): PARK CITY PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2013
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 PROSPECTOR AVE
PARK CITY UT
84060-7207
US

IV. Provider business mailing address

1901 PROSPECTOR AVE
PARK CITY UT
84060-7207
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-5001
  • Fax:
Mailing address:
  • Phone: 435-649-5001
  • 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: MARCI NICOL
Title or Position: VP OF OPERATIONS
Credential:
Phone: 801-918-4135