# CLUBHOUSE PEDIATRIC DENTISTRY OF WEST JORDAN

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** CAPSTONE LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1639654684
- **Legal business name:** CAPSTONE LLC
- **Authorized official:** MRS. JENNIFER LOUISE ROBISON (CREDENTIALING COORDINATOR)
- **Authorized official phone:** (208) 520-1514

## Contact information

- **Practice address:** 1108 E SOUTH UNION AVE, MIDVALE, UT 84047-2904
- **Practice address phone:** (208) 520-1514
- **Mailing address:** 1108 E SOUTH UNION AVE, MIDVALE, UT 84047-2904
- **Mailing address phone:** (208) 520-1514

## Taxonomy

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

## Other

- **Enumeration date:** 09/26/2018
- **Last updated:** 09/26/2018