MEDICARE: PARK CITY PEDIATRIC DENTISTRY

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

General Provider Information

NPI Number	:	1508287475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK CITY PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1901 PROSPECTOR AVE
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7207
Country	:	US
Telephone Number	:	435-649-5001
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 PROSPECTOR AVE
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7207
Country	:	US
Telephone Number	:	435-649-5001
Fax Number	:

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	MARCI NICOL
Credential	:
Telephone Number	:	801-918-4135

Provider Enumeration Date	:	12/19/2013
Last Update Date	:	12/19/2013

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Directions to “PARK CITY PEDIATRIC DENTISTRY ” Practice Location

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