Healthcare Provider Details

I. General information

NPI: 1033407150
Provider Name (Legal Business Name): TMJ THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E 50 S
AMERICAN FORK UT
84003-3837
US

IV. Provider business mailing address

355 E 50 S
AMERICAN FORK UT
84003-3837
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-0900
  • Fax: 801-756-7290
Mailing address:
  • Phone: 801-756-0900
  • Fax: 801-756-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number142879-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number142879-9922
License Number StateUT

VIII. Authorized Official

Name: DR. CARL K MCMILLAN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 801-756-0900