Provider Demographics
NPI:1487709549
Name:EMERGENCY DENTAL CARE OREM
Entity type:Organization
Organization Name:EMERGENCY DENTAL CARE OREM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-235-0911
Mailing Address - Street 1:484 W 800 N STE 202
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3728
Mailing Address - Country:US
Mailing Address - Phone:801-235-0911
Mailing Address - Fax:801-235-1911
Practice Address - Street 1:484 W 800 N STE 202
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3728
Practice Address - Country:US
Practice Address - Phone:801-235-0911
Practice Address - Fax:801-235-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid