Provider Demographics
NPI:1154963098
Name:WHITE PEAK DENTAL
Entity type:Organization
Organization Name:WHITE PEAK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-293-1234
Mailing Address - Street 1:6800 S HIGHLAND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3067
Mailing Address - Country:US
Mailing Address - Phone:801-293-1234
Mailing Address - Fax:801-305-3683
Practice Address - Street 1:6800 S HIGHLAND DR STE 100
Practice Address - Street 2:
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121-3067
Practice Address - Country:US
Practice Address - Phone:801-293-1234
Practice Address - Fax:801-305-3683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty