Healthcare Provider Details

I. General information

NPI: 1730341215
Provider Name (Legal Business Name): DHEW IND HLTH SVCS & MNTL HLTH SVCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 E 1000 SOUTH
FORT DUCHESNE UT
84026
US

IV. Provider business mailing address

6822 E. 1000 SOUTH
FORT DUCHESNE UT
84026
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-5122
  • Fax:
Mailing address:
  • Phone: 435-722-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MR. DELBERT GARY MARTIN
Title or Position: CHIEF PHARMACIST
Credential: RPH
Phone: 435-725-6874