MEDICARE: CACHE VALLEY PEDIATRIC DENTISTRY

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1962282459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CACHE VALLEY PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1624 N 200 E STE 100
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-3141
Country	:	US
Telephone Number	:	435-752-4330
Fax Number	:	435-752-6330

Provider Business Practice Location Address
First Line	:	1624 N 200 E STE 100
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-3141
Country	:	US
Telephone Number	:	435-752-4330
Fax Number	:	435-752-6330

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	TORI GIBBS
Credential	:
Telephone Number	:	435-752-4330

Provider Enumeration Date	:	10/02/2023
Last Update Date	:	10/02/2023

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Directions to “CACHE VALLEY PEDIATRIC DENTISTRY ” Practice Location

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