Healthcare Provider Details

I. General information

NPI: 1568906824
Provider Name (Legal Business Name): MSG DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 N 700 E
PROVO UT
84606-6993
US

IV. Provider business mailing address

835 N 700 E
PROVO UT
84606-6993
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-7700
  • Fax: 801-370-0762
Mailing address:
  • Phone: 801-373-7700
  • Fax: 801-370-0762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number372923
License Number StateUT

VIII. Authorized Official

Name: DR. CORBIN G MATTHEWS
Title or Position: OWNER
Credential: DMD
Phone: 801-473-6455