Basic Information
Provider Information | |||||||||
NPI: | 1629499520 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTGATE PEDIATRIC DENTISTRY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1580 E 3900 S | ||||||||
Address2: | SUITE #110 | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841241581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012728555 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1580 E 3900 S | ||||||||
Address2: | SUITE #110 | ||||||||
City: | SLC | ||||||||
State: | UT | ||||||||
PostalCode: | 841241581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012728555 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2013 | ||||||||
LastUpdateDate: | 12/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NICOL | ||||||||
AuthorizedOfficialFirstName: | MARCI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8019184135 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.