MEDICARE: DR. PRISCILA FABIANA PETRY BAUTISTA 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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	12448109-9923	UT

General Provider Information

NPI Number	:	1871159665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRISCILA FABIANA PETRY BAUTISTA DDS

Provider Business Mailing Address
First Line	:	11777 S AUTUMN RIDGE CV
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092-7345
Country	:	US
Telephone Number	:	954-397-4102
Fax Number	:

Provider Business Practice Location Address
First Line	:	168 E 5900 S STE C103
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-7262
Country	:	US
Telephone Number	:	801-875-0370
Fax Number	:

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

Provider Enumeration Date	:	05/16/2019
Last Update Date	:	12/22/2022

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