Provider Demographics
NPI:1588725097
Name:CHIDESTER, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 CENTENNIAL PKWY
Mailing Address - Street 2:SUITE 330
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10011 CENTENNIAL PKWY
Practice Address - Street 2:SUITE 330
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4156
Practice Address - Country:US
Practice Address - Phone:801-256-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141895-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice