MEDICARE: MCKINSEE BRODERICK WEYHER 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	122300000X	Dentist	59546	CA
2	122300000X	Dentist	1361	AK
3	122300000X	Dentist	8088273-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1361	OTHER	AK	DENTAL LICENSE
2	59546	OTHER	CA	DENTAL LICENSE
3	8088273-9922	OTHER	UT	UTAH DENTAL LICENSE

General Provider Information

NPI Number	:	1306152889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKINSEE BRODERICK WEYHER DDS

Provider Business Mailing Address
First Line	:	2114 S HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2807
Country	:	US
Telephone Number	:	385-399-0537
Fax Number	:	801-880-8835

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	:	385-399-0537
Fax Number	:	801-880-8835

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

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	12/31/2016

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