MEDICARE: DYLAN LANE HARMON DMD

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	11769010-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11769010-8903	OTHER	UT	UTAH DOPL
2	11769010-9922	OTHER	UT	UTAH DOPL

General Provider Information

NPI Number	:	1205454113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DYLAN LANE HARMON DMD

Provider Business Mailing Address
First Line	:	1750 N 1780 E
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-2192
Country	:	US
Telephone Number	:	435-890-0379
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 N 400 E # 3A
Second Line	:
City	:	NORTH LOGAN
State	:	UT
Zip	:	84341-7564
Country	:	US
Telephone Number	:	435-363-3595
Fax Number	:

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

Provider Enumeration Date	:	07/07/2020
Last Update Date	:	07/07/2020

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Directions to “ DYLAN LANE HARMON DMD” Practice Location

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