Healthcare Provider Details

I. General information

NPI: 1700464955
Provider Name (Legal Business Name): FAMILIES FIRST PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 W 13400 S STE 110
RIVERTON UT
84096-6483
US

IV. Provider business mailing address

PO BOX 95868
SOUTH JORDAN UT
84095-0868
US

V. Phone/Fax

Practice location:
  • Phone: 801-450-1250
  • Fax:
Mailing address:
  • Phone: 801-450-1250
  • 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: EBONIE GONZALES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 505-850-3769