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General NPI Number Information
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NPI Number | 1174626345
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Entity Type | Organization
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Legal Business Name | BAER CANYON DENTAL LLC
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 03/05/2009
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Provider Practice Location Address
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Address Line | 275 NORTH 300 WEST SUITE #404
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City | KAYSVILLE
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State | UT
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Zip | 84037
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Country | US
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Telephone | 801-544-9444
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Fax | 801-544-9443
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Provider Business Mailing Address
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Address Line | 275 NORTH 300 WEST SUITE #404
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City | KAYSVILLE
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State | UT
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Zip | 84037
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Country | US
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Telephone | 801-544-9444
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Fax | 801-544-9443
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Authorized Official
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Title or Position | OFFICE MANAGER HYGIENIST
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Name | MRS. STACEY A THOMAS
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Credential |
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Telephone | 801-544-9444
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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 | 4936704 9922
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License Number State | UT
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