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General NPI Number Information
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NPI Number | 1083921704
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Entity Type | Organization
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Legal Business Name | MOUNTAIN VIEW PEDIATRIC DENTISTRY OF LAYTON
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Dates
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Enumeration Date | 09/01/2010
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Last Update Date | 09/01/2010
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Provider Practice Location Address
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Address Line | 195 E GENTILE ST SUITE #11
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City | LAYTON
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State | UT
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Zip | 84041-3754
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Country | US
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Telephone | 801-779-2900
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Fax |
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Provider Business Mailing Address
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Address Line | 195 E GENTILE ST SUITE #11
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City | LAYTON
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State | UT
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Zip | 84041-3754
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Country | US
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Telephone | 801-779-2900
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. BRETT PACKHAM
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Credential | DDS
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Telephone | 801-779-2900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 6362621-9922
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License Number State | UT
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