MEDICARE: HIDDEN VALLEY PEDIATRIC DENTAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1841475456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIDDEN VALLEY PEDIATRIC DENTAL INC

Provider Business Mailing Address
First Line	:	114 E 12450 S STE 200
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-8060
Country	:	US
Telephone Number	:	801-495-1610
Fax Number	:	801-495-1631

Provider Business Practice Location Address
First Line	:	114 E 12450 S STE 200
Second Line	:
City	:	DRAPER
State	:	UT
Zip	:	84020-8060
Country	:	US
Telephone Number	:	801-495-1610
Fax Number	:	801-495-1631

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRENT CARL DEHART
Credential	:	D.D.S.
Telephone Number	:	801-495-1610

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	02/13/2008

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Directions to “HIDDEN VALLEY PEDIATRIC DENTAL INC ” Practice Location

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