Provider Demographics
NPI:1063063105
Name:ABUNDANT DENTAL CARE, P.C.
Entity type:Organization
Organization Name:ABUNDANT DENTAL CARE, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS RECEIVABLE, DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-849-1045
Mailing Address - Street 1:641 W 9000 S STE 2
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2580
Mailing Address - Country:US
Mailing Address - Phone:801-566-8833
Mailing Address - Fax:
Practice Address - Street 1:641 W 9000 S STE 2
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2580
Practice Address - Country:US
Practice Address - Phone:801-566-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABUNDANT DENTAL CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-20
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty