Basic Information
| Provider Information | |||||||||
| NPI: | 1720466303 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IVORY RIDGE PEDIATRIC DENTISTRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 NORTH CENTER STREET | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840430000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 N CENTER STREET | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840430000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019184135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 05/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | NICOL | ||||||||
| AuthorizedOfficialFirstName: | MARCI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8019184135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
No ID Information.