Healthcare Provider Details

I. General information

NPI: 1720465875
Provider Name (Legal Business Name): COLLEGE DENTAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 S 1480 W
OREM UT
84058-4905
US

IV. Provider business mailing address

1176 S 1480 W
OREM UT
84058-4905
US

V. Phone/Fax

Practice location:
  • Phone: 801-426-0774
  • Fax:
Mailing address:
  • Phone: 801-426-0774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9317729
License Number StateUT

VIII. Authorized Official

Name: KENNETH MOLEN
Title or Position: OWNER
Credential: DDS
Phone: 801-426-0774