Provider Demographics
NPI:1972740249
Name:RIVERSIDE DENTAL LLC
Entity type:Organization
Organization Name:RIVERSIDE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:STEVENS
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 #2
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-6896
Mailing Address - Country:US
Mailing Address - Phone:435-673-3363
Mailing Address - Fax:
Practice Address - Street 1:368 E RIVERSIDE DR
Practice Address - Street 2:BLDG #2
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6896
Practice Address - Country:US
Practice Address - Phone:435-673-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5929127-9923261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental