Provider Demographics
NPI:1235977240
Name:PROFESSIONAL DENTAL SLC LLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL SLC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:HACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-636-0110
Mailing Address - Street 1:PO BOX 1806
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1806
Mailing Address - Country:US
Mailing Address - Phone:801-785-8000
Mailing Address - Fax:801-785-4030
Practice Address - Street 1:1632 W 700 N STE A-1
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-1903
Practice Address - Country:US
Practice Address - Phone:801-785-8000
Practice Address - Fax:801-785-4030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental