Provider Demographics
NPI:1487910147
Name:LEGACY PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:LEGACY PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:C
Authorized Official - Last Name:FOLKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-710-4593
Mailing Address - Street 1:3225 W GORDON AVE
Mailing Address - Street 2:STE G
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6508
Mailing Address - Country:US
Mailing Address - Phone:801-544-3400
Mailing Address - Fax:801-544-3402
Practice Address - Street 1:3225 W GORDON AVE
Practice Address - Street 2:STE G
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6508
Practice Address - Country:US
Practice Address - Phone:801-544-3400
Practice Address - Fax:801-544-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-07
Last Update Date:2012-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8224117-99231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty