Healthcare Provider Details

I. General information

NPI: 1992179964
Provider Name (Legal Business Name): KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 11/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 S 2000 W SUITE #F-2
SYRACUSE UT
84075-9602
US

IV. Provider business mailing address

780 S 2000 W SUITE #F-2
SYRACUSE UT
84075-9602
US

V. Phone/Fax

Practice location:
  • Phone: 801-776-8176
  • Fax: 801-774-9085
Mailing address:
  • Phone: 801-776-8176
  • Fax: 801-774-9085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6362621-9922
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1477728269
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: BRETT PACKHAM
Title or Position: MEMBER
Credential: DDS
Phone: 801-217-3359