Provider Demographics
NPI:1861887838
Name:B. CHARLES PUGH D.D.S., P.C.
Entity type:Organization
Organization Name:B. CHARLES PUGH D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-254-1278
Mailing Address - Street 1:12694 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6605
Mailing Address - Country:US
Mailing Address - Phone:801-254-1278
Mailing Address - Fax:801-254-5778
Practice Address - Street 1:12694 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6605
Practice Address - Country:US
Practice Address - Phone:801-254-1278
Practice Address - Fax:801-254-5778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT140202-9922302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization