South Ogden Pediatric Dental P.C.

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

5118697-9923 Issued in UT

Legal business name

SOUTH OGDEN PEDIATRIC DENTAL P.C.

Practice address

5275 S. Adams Ave.,
Suite C
Washington Terrace, UT 84405

Phone

(801) 475-6433

Fax

(801) 334-8411

NPI assigned

Aug 4, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

M. Wade Rallison, DDS

Title

Owner

Phone

(801) 475-6433

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154649600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1308614400000",
    "number": "1104834191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5275 S. ADAMS AVE.,",
            "address_2": "SUITE C SUITE #4",
            "city": "WASHINGTON TERRACE",
            "state": "UT",
            "postal_code": "84405",
            "telephone_number": "801-475-6433",
            "fax_number": "801-334-8411"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5275 S. ADAMS AVE.,",
            "address_2": "SUITE C",
            "city": "WASHINGTON TERRACE",
            "state": "UT",
            "postal_code": "84405",
            "telephone_number": "801-475-6433",
            "fax_number": "801-334-8411"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH OGDEN PEDIATRIC DENTAL P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-04",
        "last_updated": "2011-06-21",
        "status": "A",
        "authorized_official_last_name": "RALLISON",
        "authorized_official_first_name": "M.",
        "authorized_official_middle_name": "WADE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "801-475-6433",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "UT",
            "license": "5118697-9923",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "518155919002",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Judy Ann Roybal, TRT
• Elsha Cachet Russell
• Rachel Samuelson, MD
• Sandra Jo Scott, RDH
• Jenifer Rebecca Nilson Smith, P.T.
• Rolanda Daisy Steele
• Therapeuo Health
• Timber Ridge Holdings LLC
• Amanda Kathryn Trease, COTA
• Utah Orthopaedics LLC

• Pediatric Dentistry in Washington Terrace, UT
• Providers in Washington Terrace, UT by specialty
• Pediatric Dentistry in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 21, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.