Provider Demographics
NPI:1386775153
Name:RIVERSIDE DENTAL CARE PC
Entity type:Organization
Organization Name:RIVERSIDE DENTAL CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-673-3363
Mailing Address - Street 1:368 E RIVERSIDE DR
Mailing Address - Street 2:BLDG 2A
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-673-3363
Mailing Address - Fax:435-673-0138
Practice Address - Street 1:368 E RIVERSIDE DR
Practice Address - Street 2:BLDG 2A
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-673-3363
Practice Address - Fax:435-673-0138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2645001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty