Healthcare Provider Details

I. General information

NPI: 1356795769
Provider Name (Legal Business Name): CHAD JORDAN GOLLAHER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 S 1100 E
AMERICAN FORK UT
84003-2817
US

IV. Provider business mailing address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

V. Phone/Fax

Practice location:
  • Phone: 801-756-6048
  • Fax:
Mailing address:
  • Phone: 801-473-9055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10789138-9923
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: