NPIMap

Organization Active NPI

Kids Town Pediatric Dentistry of Syracuse

  • Pediatric Dentistry
  • Syracuse, UT
National Provider Identifier
1992179964
Registry record updated Nov 13, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
6362621-9922 Issued in UT
Legal business name
KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE
Practice address
780 S 2000 W
Suite #F-2
Syracuse, UT 84075-9602
Phone
(801) 776-8176
Fax
(801) 774-9085
NPI assigned
Nov 13, 2015
Last updated
Nov 13, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 13, 2015

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

Authorized official

Name
Brett Packham, DDS
Title
Member
Phone
(801) 217-3359

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 6362621-9922 UT Primary

Addresses

Primary practice location

780 S 2000 W
Suite #F-2
Syracuse, UT 84075-9602

Mailing address

780 S 2000 W
Suite #F-2
Syracuse, UT 84075-9602
Phone (801) 776-8176

Other identifiers 1

IdentifierTypeStateIssuer
1477728269MedicaidUT

National Provider Directory

National Provider Directory

Locations

780 S 2000 W
Ste F2
Syracuse, UT 84075
Phone (801) 217-3359

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1447372800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1447372800000",
    "number": "1992179964",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "780 S 2000 W",
            "address_2": "SUITE #F-2",
            "city": "SYRACUSE",
            "state": "UT",
            "postal_code": "840759602",
            "telephone_number": "801-776-8176",
            "fax_number": "801-774-9085"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "780 S 2000 W",
            "address_2": "SUITE #F-2",
            "city": "SYRACUSE",
            "state": "UT",
            "postal_code": "840759602",
            "telephone_number": "801-776-8176",
            "fax_number": "801-774-9085"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KIDS TOWN PEDIATRIC DENTISTRY OF SYRACUSE",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-11-13",
        "last_updated": "2015-11-13",
        "status": "A",
        "authorized_official_last_name": "PACKHAM",
        "authorized_official_first_name": "BRETT",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "801-217-3359",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "UT",
            "license": "6362621-9922",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1477728269",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Syracuse, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 13, 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.