Organization
SOUTH OGDEN PEDIATRIC DENTAL P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
M. WADE RALLISON DDS (OWNER)
(801) 475-6433
Entity
Organization
Contact information
Practice address
5275 S. ADAMS AVE.,, SUITE C, WASHINGTON TERRACE, UT 84405
(801) 475-6433
(801) 334-8411
Mailing address
5275 S. ADAMS AVE.,, SUITE C SUITE #4, WASHINGTON TERRACE, UT 84405
(801) 475-6433
(801) 334-8411
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
5118697-9923
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
518155919002
—
UT
Enumeration date
08/04/2006
Last updated
06/21/2011
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