Healthcare Provider Details

I. General information

NPI: 1376656017
Provider Name (Legal Business Name): SMILEWIDE DENTAL CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5629 W. 13100 S.
HERRIMAN UT
84096
US

IV. Provider business mailing address

5629 W. 13100 S.
HERRIMAN UT
84096
US

V. Phone/Fax

Practice location:
  • Phone: 801-446-6889
  • Fax: 801-446-6881
Mailing address:
  • Phone: 801-446-6889
  • Fax: 801-446-6881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number53235209922
License Number StateUT

VIII. Authorized Official

Name: DR. RODNEY JONATHAN THORNELL
Title or Position: DOCTOR
Credential: D.M.D.
Phone: 801-446-6889