Provider Demographics
NPI:1306901566
Name:BASIN FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:BASIN FAMILY DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-722-2111
Mailing Address - Street 1:209 W 200 N
Mailing Address - Street 2:71-2
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2835
Mailing Address - Country:US
Mailing Address - Phone:435-722-2111
Mailing Address - Fax:435-722-2005
Practice Address - Street 1:209 W 200 N
Practice Address - Street 2:71-2
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2835
Practice Address - Country:US
Practice Address - Phone:435-722-2111
Practice Address - Fax:435-722-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142333-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty