Healthcare Provider Details

I. General information

NPI: 1104845890
Provider Name (Legal Business Name): THOMAS R LIDDELL D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 E SOUTH TEMPLE STE 209
SALT LAKE CITY UT
84102-1795
US

IV. Provider business mailing address

702 E SOUTH TEMPLE STE 209
SALT LAKE CITY UT
84102-1795
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-8282
  • Fax: 801-359-8902
Mailing address:
  • Phone: 801-359-8282
  • Fax: 801-359-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number136965-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: