Provider Demographics
NPI:1992880710
Name:PEDIATRIC DENTAL PC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-540-5081
Mailing Address - Street 1:1401 N HIGHWAY 89
Mailing Address - Street 2:#200
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2745
Mailing Address - Country:US
Mailing Address - Phone:801-447-5437
Mailing Address - Fax:801-447-4685
Practice Address - Street 1:1401 N HIGHWAY 89
Practice Address - Street 2:#200
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2745
Practice Address - Country:US
Practice Address - Phone:801-447-5437
Practice Address - Fax:801-447-4685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3412921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528537398004Medicaid