Healthcare Provider Details

I. General information

NPI: 1013367036
Provider Name (Legal Business Name): CITY CREEK DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 S WEST TEMPLE STE 100
SALT LAKE CITY UT
84101-1443
US

IV. Provider business mailing address

175 S WEST TEMPLE STE 100
SALT LAKE CITY UT
84101-1443
US

V. Phone/Fax

Practice location:
  • Phone: 801-364-7943
  • Fax: 801-364-3373
Mailing address:
  • Phone: 801-364-7943
  • Fax: 801-364-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7991108
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number5673900
License Number StateUT

VIII. Authorized Official

Name: WALTER LANDON BYE
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 801-364-7943