Healthcare Provider Details

I. General information

NPI: 1104291137
Provider Name (Legal Business Name): PEARL THORNDAL-STEWART
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 NORTH 200 EAST
TORREY UT
84775
US

IV. Provider business mailing address

PO BOX 750119
TORREY UT
84775-0119
US

V. Phone/Fax

Practice location:
  • Phone: 435-691-4319
  • Fax:
Mailing address:
  • Phone: 435-691-4319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number376404-0701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: