Basic Information
Provider Information | |||||||||
NPI: | 1023320728 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDREN'S CORNER PEDIATRIC DENTISTRY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 275 W 200 N STE 175 | ||||||||
Address2: |   | ||||||||
City: | LINDON | ||||||||
State: | UT | ||||||||
PostalCode: | 840425009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017692530 | ||||||||
FaxNumber: | 8017692531 | ||||||||
Practice Location | |||||||||
Address1: | 275 W 200 N STE 175 | ||||||||
Address2: |   | ||||||||
City: | LINDON | ||||||||
State: | UT | ||||||||
PostalCode: | 840425009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017692530 | ||||||||
FaxNumber: | 8017692531 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/09/2010 | ||||||||
LastUpdateDate: | 07/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SEGURA | ||||||||
AuthorizedOfficialFirstName: | STUART | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
AuthorizedOfficialTelephone: | 8017692530 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.D.S., M.S.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 7108173 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.