MEDICARE: MISS TIFFANY BROOKE MALAN RDH

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	124Q00000X	Dental Hygienist	7369176-9920	UT

General Provider Information

NPI Number	:	1790013050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS TIFFANY BROOKE MALAN RDH

Provider Business Mailing Address
First Line	:	5528 S 4225 W
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-8122
Country	:	US
Telephone Number	:	801-645-3831
Fax Number	:

Provider Business Practice Location Address
First Line	:	5642 S 900 E
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-1060
Country	:	US
Telephone Number	:	801-261-2202
Fax Number	:

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

Provider Enumeration Date	:	11/25/2009
Last Update Date	:	11/25/2009

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