Basic Information
| Provider Information | |||||||||
| NPI: | 1609182641 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COTTONWOOD PEDIATRIC DENTAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALL ABOUT SMILES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7050 S 2000 E | ||||||||
| Address2: | 110 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841213749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019433233 | ||||||||
| FaxNumber: | 8019433286 | ||||||||
| Practice Location | |||||||||
| Address1: | 7050 S 2000 E | ||||||||
| Address2: | # 110 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841213749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019433233 | ||||||||
| FaxNumber: | 8019433286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2010 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | TRISHA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4358401025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JUST KID SMILES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DMD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 1367609922 | UT | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 47532089923 | UT | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.