MEDICARE: SALT LAKE 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	122300000X	Dentist	7348465	UT
2	122300000X	Dentist	6273877	UT

General Provider Information

NPI Number	:	1538577655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT LAKE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1548 E 4500 S STE 102
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5209
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1548 E 4500 S STE 102
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5209
Country	:	US
Telephone Number	:	801-463-1900
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEFFREY RUPP
Credential	:
Telephone Number	:	801-463-1900

Provider Enumeration Date	:	08/01/2014
Last Update Date	:	08/01/2014

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Directions to “SALT LAKE PEDIATRIC DENTISTRY ” Practice Location

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