Healthcare Provider Details

I. General information

NPI: 1295424232
Provider Name (Legal Business Name): CDA PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11978 S 700 E STE 101
DRAPER UT
84020-9818
US

IV. Provider business mailing address

11978 S 700 E STE 101
DRAPER UT
84020-9818
US

V. Phone/Fax

Practice location:
  • Phone: 801-352-7002
  • Fax:
Mailing address:
  • Phone: 801-352-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LOGAN LOCKE
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 801-755-9243