Healthcare Provider Details

I. General information

NPI: 1386461283
Provider Name (Legal Business Name): HD OREM 1 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E 800 S STE B
OREM UT
84097-6386
US

IV. Provider business mailing address

370 E 800 S STE B
OREM UT
84097-6386
US

V. Phone/Fax

Practice location:
  • Phone: 385-284-0207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MEGAN TANNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 385-284-0207