Organization
BASIN FAMILY DENTAL LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TIFFANY BRAY (MANAGER)
(435) 637-2100
Entity
Organization
Contact information
Practice address
209 W 200 N # 71, ROOSEVELT, UT 84066-2835
(435) 722-2111
Mailing address
209 W 200 N # 71, ROOSEVELT, UT 84066-2835
(435) 722-2111
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
600290118011
—
UT
Enumeration date
04/26/2021
Last updated
04/26/2021
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