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General NPI Number Information
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NPI Number | 1144422429
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Entity Type | Organization
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Legal Business Name | GRANDPA'S DENTAL INC.
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 777 NORTH 500 WEST 201B
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City | PROVO
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State | UT
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Zip | 84601-1570
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Country | US
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Telephone | 801-374-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 777 NORTH 500 WEST SUITE 201B
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City | PROVO
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State | UT
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Zip | 84601-1570
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Country | US
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Telephone | 801-374-5100
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ABRAHAM RODRIGUES
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Credential |
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Telephone | 801-374-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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