# KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE

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

## Provider details

- **NPI number:** 1992179964
- **Authorized official:** BRETT PACKHAM DDS (MEMBER)
- **Authorized official phone:** (801) 217-3359

## Contact information

- **Practice address:** 780 S 2000 W, SUITE \#F-2, SYRACUSE, UT 84075-9602
- **Practice address phone:** (801) 776-8176
- **Practice address fax:** (801) 774-9085
- **Mailing address:** 780 S 2000 W, SUITE \#F-2, SYRACUSE, UT 84075-9602
- **Mailing address phone:** (801) 776-8176
- **Mailing address fax:** (801) 774-9085

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223P0221X | Pediatric Dentistry | 6362621-9922 | UT | Yes |

## Other

- **Enumeration date:** 11/13/2015
- **Last updated:** 11/13/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1477728269 | — | UT |