MEDICARE: CHERRY CREEK DENTAL

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	122300000X	Dentist

General Provider Information

NPI Number	:	1134237670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY CREEK DENTAL

Provider Business Mailing Address
First Line	:	105 S 200 W
Second Line	:
City	:	RICHMOND
State	:	UT
Zip	:	84333-1278
Country	:	US
Telephone Number	:	435-258-2301
Fax Number	:	435-258-5521

Provider Business Practice Location Address
First Line	:	105 S 200 W
Second Line	:
City	:	RICHMOND
State	:	UT
Zip	:	84333-1278
Country	:	US
Telephone Number	:	435-258-2301
Fax Number	:	435-258-5521

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MONTE LAMAR CARLSON
Credential	:	DDS
Telephone Number	:	435-258-2301

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	08/22/2020

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Directions to “CHERRY CREEK DENTAL ” Practice Location

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