Healthcare Provider Details

I. General information

NPI: 1437317146
Provider Name (Legal Business Name): DAVID R. MCDONOUGH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 S 1300 E SUITE 202
MURRAY UT
84121-6722
US

IV. Provider business mailing address

6070 S 1300 E SUITE 202
MURRAY UT
84121-6722
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-2662
  • Fax: 801-268-2009
Mailing address:
  • Phone: 801-266-2662
  • Fax: 801-268-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number67405669922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: