MEDICARE: COTTONWOOD DENTAL CENTER

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	139854	UT

General Provider Information

NPI Number	:	1700192721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTONWOOD DENTAL CENTER

Provider Business Mailing Address
First Line	:	7050 SO. HIGHLAND DR.
Second Line	:	SUITE 240
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3761
Country	:	US
Telephone Number	:	801-942-6464
Fax Number	:	801-942-6470

Provider Business Practice Location Address
First Line	:	7050 SO. HIGHLAND DR.
Second Line	:	SUITE 240
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3761
Country	:	US
Telephone Number	:	801-942-6464
Fax Number	:	801-942-6470

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DREW L JONES
Credential	:	D.M.D
Telephone Number	:	801-942-6464

Provider Enumeration Date	:	08/27/2010
Last Update Date	:	08/27/2010

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