Forever Young Dentistry PLLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

Legal business name

FOREVER YOUNG DENTISTRY PLLC

Practice address

2335 S. State Street
Ste #200
Provo, UT 84606

Phone

(801) 225-1630

Fax

(801) 225-1630

NPI assigned

Sep 30, 2015

Organization subpart

Yes

Parent organization

FOREVER YOUNG DENTISTRYAs reported in NPPES

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

Authorized official

Name

Ms. Reyna M Madriles

Title

Co-Owner

Phone

(801) 225-1630

Specialties & licenses 1

Addresses

Other identifiers 1

Part of

Forever Young Dentistry PLLC

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

{
    "created_epoch": "1443571200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1443571200000",
    "number": "1508236795",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2335 S. STATE STREET",
            "address_2": "STE #200",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84606",
            "telephone_number": "801-225-1630",
            "fax_number": "801-404-5802"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2335 S. STATE STREET",
            "address_2": "STE #200",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84606",
            "telephone_number": "801-225-1630",
            "fax_number": "801-225-1630"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOREVER YOUNG DENTISTRY PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FOREVER YOUNG DENTISTRY",
        "enumeration_date": "2015-09-30",
        "last_updated": "2015-09-30",
        "status": "A",
        "authorized_official_last_name": "MADRILES",
        "authorized_official_first_name": "REYNA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CO-OWNER",
        "authorized_official_telephone_number": "801-225-1630",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "UT",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "564618729-001",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Betty Jean Ford, LCSW
• Larry Creed Ford Jr., M.D.
• Morgan Robinson Ford
• Thomas Michael Ford, D.D.S.
• Kyle Blake Fordham, MD
• Gretta Snyder Fors, BSN, MSN, RN, NP-C
• Steven R Forsey, AUD
• Erin Forsyth
• Jade Alexandra Forsythe
• Michael Forvil

• Dental Clinic/Center in Provo, UT
• Providers in Provo, UT by specialty
• Dental Clinic/Center in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 30, 2015; 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.