MEDICARE: DR. JONATHAN FIFE RICHARDS D.D.S., M.S.

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	5348402-9922	UT
2	1223E0200X	Endodontics	5348402-9922	UT

General Provider Information

NPI Number	:	1548254345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN FIFE RICHARDS D.D.S., M.S.

Provider Business Mailing Address
First Line	:	4918 W HAVEN RD
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-6839
Country	:	US
Telephone Number	:	952-201-3643
Fax Number	:

Provider Business Practice Location Address
First Line	:	5991 S 3500 W
Second Line	:	SUITE 200
City	:	ROY
State	:	UT
Zip	:	84067-6701
Country	:	US
Telephone Number	:	801-779-2700
Fax Number	:

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

Provider Enumeration Date	:	09/07/2005
Last Update Date	:	08/25/2008

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