Healthcare Provider Details

I. General information

NPI: 1649117557
Provider Name (Legal Business Name): ENOVAA DENTAL IMPLANT CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 E WINCHESTER ST
MURRAY UT
84107-7564
US

IV. Provider business mailing address

795 E WINCHESTER ST
MURRAY UT
84107-7564
US

V. Phone/Fax

Practice location:
  • Phone: 801-630-8811
  • Fax:
Mailing address:
  • Phone: 801-630-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PABLO OLLIVERIA BAUTISTA
Title or Position: GENERAL DENTRIST
Credential: DDS
Phone: 801-630-8811