1154862126 NPI number — JORDAN LANDING DENTAL MANAGEMENT

Table of content: (NPI 1154862126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154862126 NPI number — JORDAN LANDING DENTAL MANAGEMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JORDAN LANDING DENTAL MANAGEMENT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154862126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7478 S CAMPUS VIEW DR
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84084-1966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-280-6911
Provider Business Mailing Address Fax Number:
801-280-6955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7478 S CAMPUS VIEW DR
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84084-1966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-280-6911
Provider Business Practice Location Address Fax Number:
801-280-6955
Provider Enumeration Date:
03/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
801-280-6911

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  344165 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com