Healthcare Provider Details

I. General information

NPI: 1609556323
Provider Name (Legal Business Name): MDG - MAPLETON DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N 1600 W
MAPLETON UT
84664-3103
US

IV. Provider business mailing address

108 N 1600 W
MAPLETON UT
84664-3103
US

V. Phone/Fax

Practice location:
  • Phone: 801-491-6844
  • Fax:
Mailing address:
  • Phone: 801-491-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JAMES COLE MCWHORTER
Title or Position: OWNER
Credential:
Phone: 801-592-4360