=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265685176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLLADAY CENTER DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2008
-----------------------------------------------------
Last Update Date | 10/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2160 E 4500 S STE 3
-----------------------------------------------------
City | HOLLADAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84117-4499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-277-9213
-----------------------------------------------------
Fax | 801-277-0956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2160 E 4500 S STE 3
-----------------------------------------------------
City | HOLLADAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84117-4499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-277-9213
-----------------------------------------------------
Fax | 801-277-0956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DOCTOR
-----------------------------------------------------
Name | DR. NICHOLAS B LAFEBER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 801-277-9213
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 320562
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------