Healthcare Provider Details

I. General information

NPI: 1740687706
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS - UTAH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 N 900 W STE A
AMERICAN FORK UT
84003-5200
US

IV. Provider business mailing address

476 N 900 W STE A
AMERICAN FORK UT
84003-5200
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-5522
  • Fax: 801-758-8499
Mailing address:
  • Phone: 801-756-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LILIANA MARTINEZ
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 949-308-9792