MEDICARE: WOODLAND PARK DENTAL P.C.

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	1223G0001X	General Practice Dentistry	358446-9923	UT

General Provider Information

NPI Number	:	1477696235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODLAND PARK DENTAL P.C.

Provider Business Mailing Address
First Line	:	880 HERITAGE PARK BLVD
Second Line	:	SUITE 220
City	:	LAYTON
State	:	UT
Zip	:	84041-5676
Country	:	US
Telephone Number	:	801-728-4688
Fax Number	:	801-728-4868

Provider Business Practice Location Address
First Line	:	880 HERITAGE PARK BLVD
Second Line	:	SUITE 220
City	:	LAYTON
State	:	UT
Zip	:	84041-5676
Country	:	US
Telephone Number	:	801-728-4688
Fax Number	:	801-728-4868

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. CAESAR R. HEARNE
Credential	:	D.D.S.
Telephone Number	:	801-728-4688

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	08/22/2020

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