Provider Demographics
NPI:1104903152
Name:UTAH DENTAL PROVIDERS
Entity type:Organization
Organization Name:UTAH DENTAL PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CIO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EVERETT
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-755-0800
Mailing Address - Street 1:4100 MCEWEN RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5113
Mailing Address - Country:US
Mailing Address - Phone:972-755-0800
Mailing Address - Fax:
Practice Address - Street 1:1909 W 4700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-1105
Practice Address - Country:US
Practice Address - Phone:801-968-9548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX184581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty