Healthcare Provider Details

I. General information

NPI: 1457194979
Provider Name (Legal Business Name): AD1 MURRAY ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

586 W 5300 S STE 101
MURRAY UT
84123-5685
US

IV. Provider business mailing address

586 W 5300 S STE 101
MURRAY UT
84123-5685
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-1500
  • Fax: 801-262-1514
Mailing address:
  • Phone: 801-262-1500
  • Fax: 801-262-1514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LAUREL MORTENSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-262-1500