MEDICARE: DEMILLE MACKAY DENTAL

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

General Provider Information

NPI Number	:	1609739242
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEMILLE MACKAY DENTAL

Provider Business Mailing Address
First Line	:	3454 S 4800 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-1705
Country	:	US
Telephone Number	:	801-969-3025
Fax Number	:	801-969-6115

Provider Business Practice Location Address
First Line	:	3454 S 4800 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-1705
Country	:	US
Telephone Number	:	801-969-3025
Fax Number	:	801-969-6115

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTOPHER DEMILLE
Credential	:	DMD
Telephone Number	:	801-969-3025

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/09/2025

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