Healthcare Provider Details

I. General information

NPI: 1306421102
Provider Name (Legal Business Name): ROCKY MOUNTAIN ENDODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5334 S WOODROW ST # 201
SALT LAKE CITY UT
84107-5838
US

IV. Provider business mailing address

5334 S WOODROW ST # 201
SALT LAKE CITY UT
84107-5838
US

V. Phone/Fax

Practice location:
  • Phone: 801-833-6995
  • Fax: 801-281-1980
Mailing address:
  • Phone: 801-833-6995
  • Fax: 801-281-1980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL MADSEN
Title or Position: ENDODONTIST
Credential: DDS
Phone: 801-942-8686