Healthcare Provider Details

I. General information

NPI: 1104039809
Provider Name (Legal Business Name): MICHAEL KENT MATHESON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 WASATCH BLVD SUITE 4
SALT LAKE CITY UT
84124-2216
US

IV. Provider business mailing address

3939 WASATCH BLVD SUITE 4
SALT LAKE CITY UT
84124-2216
US

V. Phone/Fax

Practice location:
  • Phone: 801-424-0027
  • Fax: 801-424-0029
Mailing address:
  • Phone: 801-424-0027
  • Fax: 801-424-0029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number362747-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: