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Organization
PROVO PEDIATRIC DENTAL
Active
Organization
PROVO PEDIATRIC DENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BARBARA MCCOURT (OFFICE MANAGER)
(435) 637-9590
Entity
Organization
Contact information
Practice address
745 N 500 W, PROVO, UT 84601-1472
(801) 373-4200
(801) 373-0816
Mailing address
391 N 400 E, PRICE, UT 84501-2537
(435) 637-9590
(435) 637-2228
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
NULL
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1598830291
TYPE 1 NPI
UT
01
—
1811446727
TYPE 1 NPI
UT
01
—
1912072620
TYPE 1 NPI
UT
Enumeration date
02/01/2023
Last updated
02/01/2023
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