Provider Demographics
NPI:1447623830
Name:GREAT SMILES DENTAL CLINIC LLC
Entity type:Organization
Organization Name:GREAT SMILES DENTAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GMP
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-355-1434
Mailing Address - Street 1:333 E MAIN ST
Mailing Address - Street 2:#351
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4200
Mailing Address - Country:US
Mailing Address - Phone:801-642-4080
Mailing Address - Fax:
Practice Address - Street 1:7410 S CREEK RD
Practice Address - Street 2:#303
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6140
Practice Address - Country:US
Practice Address - Phone:801-642-4080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT90307051223G0001X
UT1351811223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty