Provider Demographics
NPI:1174070015
Name:PEDIATRIC DENTAL CARE
Entity type:Organization
Organization Name:PEDIATRIC DENTAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:J
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-798-2100
Mailing Address - Street 1:497 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-3002
Mailing Address - Country:US
Mailing Address - Phone:801-798-2100
Mailing Address - Fax:801-798-9977
Practice Address - Street 1:497 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-3002
Practice Address - Country:US
Practice Address - Phone:801-798-2100
Practice Address - Fax:801-798-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363178-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529511826002Medicaid
UT528178604002Medicaid