Provider Demographics
NPI:1063923258
Name:PROVO FAMILY DENTISTRY, LLC
Entity type:Organization
Organization Name:PROVO FAMILY DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-373-2693
Mailing Address - Street 1:1355 N UNIVERSITY AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2721
Mailing Address - Country:US
Mailing Address - Phone:801-373-2693
Mailing Address - Fax:
Practice Address - Street 1:1355 N UNIVERSITY AVE STE 310
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2721
Practice Address - Country:US
Practice Address - Phone:801-373-2693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275985-9922261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental