Provider Demographics
NPI:1487295218
Name:STANSBURY PARK PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:STANSBURY PARK PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-580-8800
Mailing Address - Street 1:11996 S ANTHEM PARK BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5643
Mailing Address - Country:US
Mailing Address - Phone:435-580-8800
Mailing Address - Fax:
Practice Address - Street 1:263 COUNTRY CLB STE 102
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9602
Practice Address - Country:US
Practice Address - Phone:435-580-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1346761152OtherNPI
UT1811237076OtherNPI
UT1275821415OtherNPI