Healthcare Provider Details

I. General information

NPI: 1972794030
Provider Name (Legal Business Name): DIRK MURDOCK LIGHTHALL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 03/02/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 N HWY 89 STE 201
PLEASANT VIEW UT
84404-1231
US

IV. Provider business mailing address

2797 N HIGHWAY 89 STE 201
PLEASANT VIEW UT
84404-1231
US

V. Phone/Fax

Practice location:
  • Phone: 801-737-2410
  • Fax:
Mailing address:
  • Phone: 801-737-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD07533
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6592134-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: