MEDICARE: SUGAR HOUSE DENTAL CARE

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	9187494-9921	UT

General Provider Information

NPI Number	:	1205203981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGAR HOUSE DENTAL CARE

Provider Business Mailing Address
First Line	:	3821 EAGLE RIDGE CT
Second Line	:
City	:	HAMPSTEAD
State	:	MD
Zip	:	21074-1360
Country	:	US
Telephone Number	:	410-804-2709
Fax Number	:

Provider Business Practice Location Address
First Line	:	2114 S HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2807
Country	:	US
Telephone Number	:	540-419-9422
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE ASSISTANT
Name	:	ANN MARIE WILSON
Credential	:
Telephone Number	:	540-419-9422

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	08/28/2015

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