Healthcare Provider Details

I. General information

NPI: 1659714392
Provider Name (Legal Business Name): RUSSELL SEAMONS DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4902 S 1900 W STE 2
ROY UT
84067-2993
US

IV. Provider business mailing address

4902 S 1900 W STE 2
ROY UT
84067-2993
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-1234
  • Fax: 801-773-9611
Mailing address:
  • Phone: 801-773-1234
  • Fax: 801-773-9611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1409289922
License Number StateUT

VIII. Authorized Official

Name: DR. RUSSELL GLENN SEAMONS
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 801-773-1234