Provider Demographics
NPI:1902688492
Name:PROFESSIONAL DENTAL RIVERTON LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL RIVERTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-636-0110
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1806
Mailing Address - Country:US
Mailing Address - Phone:801-785-8000
Mailing Address - Fax:801-785-4030
Practice Address - Street 1:13686 S REDWOOD RD STE C
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-5907
Practice Address - Country:US
Practice Address - Phone:801-446-8100
Practice Address - Fax:801-785-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty