Provider Demographics
NPI:1154049872
Name:LEGACY TRAIL FAMILY DENTAL
Entity type:Organization
Organization Name:LEGACY TRAIL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MILNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-698-4555
Mailing Address - Street 1:1014 W GENTILE ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4646
Mailing Address - Country:US
Mailing Address - Phone:801-698-4555
Mailing Address - Fax:
Practice Address - Street 1:1014 W GENTILE ST STE A
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4646
Practice Address - Country:US
Practice Address - Phone:801-698-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty