Healthcare Provider Details

I. General information

NPI: 1144605403
Provider Name (Legal Business Name): SHAD B MACKERT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2015
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12459 S 300 E STE 202
DRAPER UT
84020-1899
US

IV. Provider business mailing address

12459 S 300 E STE 202
DRAPER UT
84020-1899
US

V. Phone/Fax

Practice location:
  • Phone: 385-430-1200
  • Fax:
Mailing address:
  • Phone: 854-301-2003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901021479
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number10220776-8903
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901021479
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: