Basic Information
| Provider Information | |||||||||
| NPI: | 1720649098 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDY MODERN DENTISTRY, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 E 10600 S STE 104 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840704124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013053736 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2019 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | BURR | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7148458500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.