MEDICARE: DR. STEPHEN D HASLAM DDS

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	1223G0001X	General Practice Dentistry	143673-9923	UT

General Provider Information

NPI Number	:	1124147830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN D HASLAM DDS

Provider Business Mailing Address
First Line	:	6065 FASHION BLVD
Second Line	:	SUITE 275
City	:	MURRAY
State	:	UT
Zip	:	84107-7381
Country	:	US
Telephone Number	:	801-262-4628
Fax Number	:	801-262-9260

Provider Business Practice Location Address
First Line	:	6065 FASHION BLVD
Second Line	:	SUITE 275
City	:	MURRAY
State	:	UT
Zip	:	84107-7381
Country	:	US
Telephone Number	:	801-262-4628
Fax Number	:	801-262-9260

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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