Healthcare Provider Details

I. General information

NPI: 1881069177
Provider Name (Legal Business Name): INTERMOUNTAIN DENTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 N HIGHWAY 89 SUITE 200
PLEASANT VIEW UT
84404-1216
US

IV. Provider business mailing address

2797 N HIGHWAY 89 SUITE 200
PLEASANT VIEW UT
84404-1216
US

V. Phone/Fax

Practice location:
  • Phone: 801-782-5682
  • Fax: 801-786-0520
Mailing address:
  • Phone: 801-782-5682
  • Fax: 801-786-0520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number145326-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number145288-9922
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number137712-9922
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8598613-9924
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9371431-9921
License Number StateUT
# 6
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8041458
License Number StateUT

VIII. Authorized Official

Name: MS. VICKI LEWIS
Title or Position: SPECIALIST COORDINATOR
Credential:
Phone: 801-782-5682