MEDICARE: JUSTIN VANBIBBER DMD PC

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	1223P0221X	Pediatric Dentistry	9429669	UT

General Provider Information

NPI Number	:	1821525288
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUSTIN VANBIBBER DMD PC

Provider Business Mailing Address
First Line	:	4775 W DAYBREAK PKWY STE 103
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-5139
Country	:	US
Telephone Number	:	801-999-4640
Fax Number	:

Provider Business Practice Location Address
First Line	:	4775 W DAYBREAK PKWY STE 103
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84009-5139
Country	:	US
Telephone Number	:	801-999-4640
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CHRISTINA OJEDA
Credential	:
Telephone Number	:	253-347-9917

Provider Enumeration Date	:	05/17/2017
Last Update Date	:	07/21/2022

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