Healthcare Provider Details

I. General information

NPI: 1477892685
Provider Name (Legal Business Name): ELITE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 N WEST STATE RD
AMERICAN FORK UT
84003-1419
US

IV. Provider business mailing address

218 N WEST STATE RD
AMERICAN FORK UT
84003-1419
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-7737
  • Fax: 801-763-7757
Mailing address:
  • Phone: 801-763-7737
  • Fax: 801-763-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5148371-9922
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5070492-9922
License Number StateUT

VIII. Authorized Official

Name: DR. STEVEN BRAITHWAITE
Title or Position: OWNER
Credential: D.D.S.
Phone: 801-763-7737