Healthcare Provider Details

I. General information

NPI: 1073010955
Provider Name (Legal Business Name): ROCKY MOUNTAIN DENTAL & SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 04/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 N 1600 W
OGDEN UT
84404
US

IV. Provider business mailing address

2703 N 1600 W
OGDEN UT
84404
US

V. Phone/Fax

Practice location:
  • Phone: 435-225-0834
  • Fax:
Mailing address:
  • Phone: 435-225-0834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9418886
License Number StateUT

VIII. Authorized Official

Name: RYKER WELLS
Title or Position: DENTIST
Credential: DMD
Phone: 801-737-4650