Provider Demographics
NPI:1609182641
Name:COTTONWOOD PEDIATRIC DENTAL
Entity type:Organization
Organization Name:COTTONWOOD PEDIATRIC DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-840-1025
Mailing Address - Street 1:7050 S 2000 E
Mailing Address - Street 2:110
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3749
Mailing Address - Country:US
Mailing Address - Phone:801-943-3233
Mailing Address - Fax:801-943-3286
Practice Address - Street 1:7050 S 2000 E
Practice Address - Street 2:# 110
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3749
Practice Address - Country:US
Practice Address - Phone:801-943-3233
Practice Address - Fax:801-943-3286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUST KID SMILES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47532089923122300000X
UT1367609922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty