Healthcare Provider Details

I. General information

NPI: 1497112338
Provider Name (Legal Business Name): THEODORE ROBERT SMALL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MEDICAL DR
MONUMENT VALLEY UT
84536-7705
US

IV. Provider business mailing address

30 W MEDICAL DR
MONUMENT VALLEY UT
84536-7705
US

V. Phone/Fax

Practice location:
  • Phone: 435-727-3004
  • Fax:
Mailing address:
  • Phone: 510-239-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number140487-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: