MEDICARE: COTTONWOOD ENDODONTICS 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	261QD0000X	Dental Clinic/Center	1404979923	UT

General Provider Information

NPI Number	:	1275665325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTONWOOD ENDODONTICS PC

Provider Business Mailing Address
First Line	:	4252 HIGHLAND DR
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2670
Country	:	US
Telephone Number	:	801-278-3636
Fax Number	:	801-424-0833

Provider Business Practice Location Address
First Line	:	4252 HIGHLAND DR
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2670
Country	:	US
Telephone Number	:	801-278-3636
Fax Number	:	801-424-0833

Authorized Official
Title or Position	:	PRES SEC
Name	:	DR. ROGER KAY WARREN
Credential	:	DDS
Telephone Number	:	801-278-3636

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	08/22/2020

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