Provider Demographics
NPI:1962282459
Name:CACHE VALLEY PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:CACHE VALLEY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TORI
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-752-4330
Mailing Address - Street 1:1624 N 200 E STE 100
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-3141
Mailing Address - Country:US
Mailing Address - Phone:435-752-4330
Mailing Address - Fax:435-752-6330
Practice Address - Street 1:1624 N 200 E STE 100
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-3141
Practice Address - Country:US
Practice Address - Phone:435-752-4330
Practice Address - Fax:435-752-6330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental