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General NPI Number Information
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NPI Number | 1558672758
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Entity Type | Organization
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Legal Business Name | MAIN PLAZA DENTAL
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Dates
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Enumeration Date | 06/23/2010
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Last Update Date | 06/23/2010
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Provider Practice Location Address
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Address Line | 312 N MAIN ST
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City | SPANISH FORK
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State | UT
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Zip | 84660-1735
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Country | US
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Telephone | 801-794-9684
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Fax | 801-798-9474
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Provider Business Mailing Address
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Address Line | 312 N MAIN ST
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City | SPANISH FORK
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State | UT
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Zip | 84660-1735
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Country | US
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Telephone | 801-794-9684
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Fax | 801-798-9474
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. AVERY LYNN BRERETON
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Credential |
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Telephone | 801-794-9684
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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 | 6947302
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5346167
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License Number State | UT
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