Healthcare Provider Details

I. General information

NPI: 1710801154
Provider Name (Legal Business Name): THERESA ANN MARTIN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 N 1200 E
LEHI UT
84043-2446
US

IV. Provider business mailing address

181 N 1200 E
LEHI UT
84043-2446
US

V. Phone/Fax

Practice location:
  • Phone: 801-855-0555
  • Fax:
Mailing address:
  • Phone: 801-855-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14293266-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: