Healthcare Provider Details

I. General information

NPI: 1396579942
Provider Name (Legal Business Name): PINNACLE DENTAL PARTNERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W 200 N
ROOSEVELT UT
84066-2835
US

IV. Provider business mailing address

516 W PALO VERDE WAY
IVINS UT
84738-1207
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

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