MEDICARE: NEXUS DENTAL GROUP PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	80174279922	UT

General Provider Information

NPI Number	:	1013416742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEXUS DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	2725 E PARLEYS WAY STE 150
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1659
Country	:	US
Telephone Number	:	801-808-2061
Fax Number	:	801-808-2061

Provider Business Practice Location Address
First Line	:	2725 E PARLEYS WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1667
Country	:	US
Telephone Number	:	801-808-2061
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	CLINTON SORENSEN
Credential	:	DDS
Telephone Number	:	801-808-2061

Provider Enumeration Date	:	02/08/2018
Last Update Date	:	02/08/2018

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