| Organization Name: | SOUTH OGDEN PEDIATRIC DENTAL P.C. |
| NPI Number: | 1104834191 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | M. WADE RALLISON (OWNER) |
| Mailing Address: | 5275 S. Adams Ave., Suite C Washington Terrace |
| State: | UT US |
| Postal Code: | 84405 |
| Phone Number: | 8014756433 |
| Fax Number: | 8013348411 |
| NPI Enumeration Date: | 08/04/2006 |
| NPI Last Update Date: | 06/21/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1223P0221X |
| License Number: | 5118697-9923 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Dental Providers |
| Taxonomy Classification: | Dentist |
| Taxonomy Specialization: | Pediatric Dentistry |
| Taxonomy Definition: | An age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. |