# PROVO PEDIATRIC DENTAL

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1184320293
- **Authorized official:** BARBARA MCCOURT (OFFICE MANAGER)
- **Authorized official phone:** (435) 637-9590

## Contact information

- **Practice address:** 745 N 500 W, PROVO, UT 84601-1472
- **Practice address phone:** (801) 373-4200
- **Practice address fax:** (801) 373-0816
- **Mailing address:** 391 N 400 E, PRICE, UT 84501-2537
- **Mailing address phone:** (435) 637-9590
- **Mailing address fax:** (435) 637-2228

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | — | NULL | Yes |
| 1223P0221X | Pediatric Dentistry | — | — | Yes |

## Other

- **Enumeration date:** 02/01/2023
- **Last updated:** 02/01/2023

## 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 |