Healthcare Provider Details

I. General information

NPI: 1225249683
Provider Name (Legal Business Name): SOUTHRIDGE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2651 W. 10400 S. #103
SOUTH JORDAN UT
84095
US

IV. Provider business mailing address

2651 W. 10400 S. #103
SOUTH JORDAN UT
84095
US

V. Phone/Fax

Practice location:
  • Phone: 801-445-1515
  • Fax: 801-446-5290
Mailing address:
  • Phone: 801-445-1515
  • Fax: 801-446-5290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5667938
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number343291
License Number StateUT

VIII. Authorized Official

Name: DAVID C ROTH
Title or Position: OWNER
Credential: DDS
Phone: 801-446-1515