MEDICARE: DR. DANIEL STANFORD POULSON DDS

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	136941-9922	UT

General Provider Information

NPI Number	:	1669590659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL STANFORD POULSON DDS

Provider Business Mailing Address
First Line	:	2180 E 4500 S STE 270
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4023
Country	:	US
Telephone Number	:	801-278-8481
Fax Number	:	801-278-3357

Provider Business Practice Location Address
First Line	:	2180 E 4500 S STE 270
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4023
Country	:	US
Telephone Number	:	801-278-8481
Fax Number	:	801-278-3357

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

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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