Healthcare Provider Details

I. General information

NPI: 1578229233
Provider Name (Legal Business Name): ALLEN-TAINTOR DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 JACKSON AVE STE 2
OGDEN UT
84403-1979
US

IV. Provider business mailing address

3860 JACKSON AVE STE 2
OGDEN UT
84403-1979
US

V. Phone/Fax

Practice location:
  • Phone: 801-627-0515
  • Fax: 801-627-0517
Mailing address:
  • Phone: 801-627-0515
  • Fax: 801-627-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DIANE W CHRISTENSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-627-0515