Healthcare Provider Details

I. General information

NPI: 1437386117
Provider Name (Legal Business Name): LARK G ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 06/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1729 SIDEWINDER DR STE 102
PARK CITY UT
84060-7322
US

IV. Provider business mailing address

1729 SIDEWINDER DR STE 102
PARK CITY UT
84060-7322
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-9492
  • Fax:
Mailing address:
  • Phone: 435-649-9492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number4751658-9920
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: