Healthcare Provider Details

I. General information

NPI: 1194710681
Provider Name (Legal Business Name): ANDREW FENTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W MAIN STREET CT STE 200
ALPINE UT
84004-5602
US

IV. Provider business mailing address

155 S. 100 W.
ALPINE UT
84004
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-9779
  • Fax:
Mailing address:
  • Phone: 801-756-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number47253509921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: