1396579942 NPI number — PINNACLE DENTAL PARTNERS

Table of content: (NPI 1396579942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396579942 NPI number — PINNACLE DENTAL PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINNACLE DENTAL PARTNERS
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:
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:
1396579942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
516 W PALO VERDE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IVINS
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84738-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 W 200 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROOSEVELT
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84066-2835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-722-2111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TANUVASA
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
385-216-4421

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 124Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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