Healthcare Provider Details

I. General information

NPI: 1205233855
Provider Name (Legal Business Name): MODERN DENTAL PROFESSIONALS - UTAH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S. 500 WEST, #A
BOUNTIFUL UT
84010
US

IV. Provider business mailing address

8415 DATAPOINT DR STE 1020
SAN ANTONIO TX
78229-3277
US

V. Phone/Fax

Practice location:
  • Phone: 801-296-1617
  • Fax:
Mailing address:
  • Phone: 210-929-2814
  • Fax: 210-615-3626

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: 493-089-7929