=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821516063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER CROSSING DENTAL PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12427 SOUTH 4000 WEST SUITE #200
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-254-8812
-----------------------------------------------------
Fax | 801-254-4650
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12427 SOUTH 4000 WEST SUITE #200
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-254-8812
-----------------------------------------------------
Fax | 801-254-4650
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | DR. JOHN PETERSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-254-8812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 7020843
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------