Healthcare Provider Details

I. General information

NPI: 1629808779
Provider Name (Legal Business Name): PIINNACLE DENTAL PARRTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W STATE RD STE 201
PLEASANT GROVE UT
84062-2116
US

IV. Provider business mailing address

516 W PALO VERDE WAY
IVINS UT
84738-1207
US

V. Phone/Fax

Practice location:
  • Phone: 385-216-4421
  • Fax:
Mailing address:
  • Phone: 385-216-4421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW TANUVASA
Title or Position: PRESIDENT
Credential:
Phone: 385-216-4421