Provider Demographics
NPI:1972782621
Name:ORTHODONTIC SPECIALISTS LLC
Entity type:Organization
Organization Name:ORTHODONTIC SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-673-9661
Mailing Address - Street 1:640 EAST 700 SOUTH
Mailing Address - Street 2:SUITE 301
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770
Mailing Address - Country:US
Mailing Address - Phone:435-673-9661
Mailing Address - Fax:435-673-6473
Practice Address - Street 1:640 EAST 700 SOUTH
Practice Address - Street 2:SUITE 301
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-673-9661
Practice Address - Fax:435-673-6473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT618643099211223X0400X
UT13040299211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty