Healthcare Provider Details

I. General information

NPI: 1629841341
Provider Name (Legal Business Name): PLAIN CITY FAMILY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2384 N 4350 W
PLAIN CITY UT
84404-9617
US

IV. Provider business mailing address

3968 W 5700 S
ROY UT
84067-9176
US

V. Phone/Fax

Practice location:
  • Phone: 801-948-0673
  • Fax:
Mailing address:
  • Phone: 801-376-6494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PETER CHRISTIAN MORTENSON
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 801-948-0673