Provider Demographics
NPI:1154862126
Name:JORDAN LANDING DENTAL MANAGEMENT
Entity type:Organization
Organization Name:JORDAN LANDING DENTAL MANAGEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-280-6911
Mailing Address - Street 1:7478 S CAMPUS VIEW DR
Mailing Address - Street 2:STE 202
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-1966
Mailing Address - Country:US
Mailing Address - Phone:801-280-6911
Mailing Address - Fax:801-280-6955
Practice Address - Street 1:7478 S CAMPUS VIEW DR
Practice Address - Street 2:STE 202
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-1966
Practice Address - Country:US
Practice Address - Phone:801-280-6911
Practice Address - Fax:801-280-6955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT344165305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization