Provider Demographics
NPI:1174626345
Name:BAER CANYON DENTAL LLC
Entity type:Organization
Organization Name:BAER CANYON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER HYGIENIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-544-9444
Mailing Address - Street 1:275 NORTH 300 WEST
Mailing Address - Street 2:SUITE #404
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037
Mailing Address - Country:US
Mailing Address - Phone:801-544-9444
Mailing Address - Fax:801-544-9443
Practice Address - Street 1:275 NORTH 300 WEST
Practice Address - Street 2:SUITE #404
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037
Practice Address - Country:US
Practice Address - Phone:801-544-9444
Practice Address - Fax:801-544-9443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4936704 9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty