Provider Demographics
NPI:1992253991
Name:KIDS TOWN PEDIATRIC DENTISTRY, PLLC
Entity type:Organization
Organization Name:KIDS TOWN PEDIATRIC DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AIMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-217-3359
Mailing Address - Street 1:3540 W 6000 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-9071
Mailing Address - Country:US
Mailing Address - Phone:801-217-3359
Mailing Address - Fax:801-217-3950
Practice Address - Street 1:3540 W 6000 S
Practice Address - Street 2:SUITE 200
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9071
Practice Address - Country:US
Practice Address - Phone:801-217-3359
Practice Address - Fax:801-217-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT63484751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty