MEDICARE: DENNIS DEDECKER DDS, PC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	1356659924	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000058020	OTHER	UT	MEDICARE GROUP
6	190000851	OTHER	UT	RAILROAD MEDICARE #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	35697	OTHER	UT	DMBA PROVIDER #
3	43-00008	OTHER	UT	UNITEDHEALTH CARE (UHC) #
4	64163	OTHER	UT	PUBLIC EMPLOYEES (PEHP) #
5	107004925101	OTHER	UT	SELECTHEALTH #
7	190644	OTHER	UT	UNITED CONCORDIA #
8	870344080DE1	OTHER	UT	EDUCATORS MUTUAL #

General Provider Information

NPI Number	:	1073516688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENNIS DEDECKER DDS, PC

Provider Business Mailing Address
First Line	:	447 E 700 N TWIN CREEK CIRCLE
Second Line	:
City	:	KAYSVILLE
State	:	UT
Zip	:	84037
Country	:	US
Telephone Number	:	801-544-2863
Fax Number	:

Provider Business Practice Location Address
First Line	:	2185 N 1700 W
Second Line	:	#204
City	:	LAYTON
State	:	UT
Zip	:	84041-1154
Country	:	US
Telephone Number	:	801-773-9790
Fax Number	:	801-773-9792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	04/05/2011

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Directions to “ DENNIS DEDECKER DDS, PC” Practice Location

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