Healthcare Provider Details

I. General information

NPI: 1669745477
Provider Name (Legal Business Name): PLATINUM DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 E 5900 S SUITE 200
MURRAY UT
84107-5421
US

IV. Provider business mailing address

279 E 5900 S SUITE 200
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-293-1234
  • Fax: 801-293-0287
Mailing address:
  • Phone: 801-293-1234
  • Fax: 801-293-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number12604477-003-STC
License Number StateUT

VIII. Authorized Official

Name: MR. VINCENT DILLEY
Title or Position: OWNER
Credential:
Phone: 801-655-3788