Provider Demographics
NPI:1730714783
Name:SOUTH HILLS PEDIATRIC DENTAL SPECIALISTS, LLC
Entity type:Organization
Organization Name:SOUTH HILLS PEDIATRIC DENTAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-589-3150
Mailing Address - Street 1:4013 W 13400 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6410
Mailing Address - Country:US
Mailing Address - Phone:385-210-1000
Mailing Address - Fax:
Practice Address - Street 1:4013 W 13400 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6410
Practice Address - Country:US
Practice Address - Phone:385-210-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty