Healthcare Provider Details

I. General information

NPI: 1689310948
Provider Name (Legal Business Name): UTAH MODERN MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 N ASHTON BLVD STE 450
LEHI UT
84043-6153
US

IV. Provider business mailing address

3300 N ASHTON BLVD STE 450
LEHI UT
84043-6153
US

V. Phone/Fax

Practice location:
  • Phone: 385-455-7170
  • Fax: 888-823-5887
Mailing address:
  • Phone: 385-455-7170
  • Fax: 888-823-5887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVE BULLOCK
Title or Position: OWNER
Credential:
Phone: 385-455-7170