Provider Demographics
NPI:1992119390
Name:ABC PEDIATRIC DENTISTRY, PC
Entity type:Organization
Organization Name:ABC PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:C
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-787-2223
Mailing Address - Street 1:65 N GATEWAY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-6102
Mailing Address - Country:US
Mailing Address - Phone:435-787-2223
Mailing Address - Fax:435-752-9296
Practice Address - Street 1:65 N GATEWAY DR STE 1
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-6102
Practice Address - Country:US
Practice Address - Phone:435-787-2223
Practice Address - Fax:435-752-9296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT58542241223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty