Healthcare Provider Details

I. General information

NPI: 1205404290
Provider Name (Legal Business Name): ENHANCE DENTAL- TROLLEY PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E 500 S
SALT LAKE CITY UT
84102-2707
US

IV. Provider business mailing address

530 E 500 S
SALT LAKE CITY UT
84102-2707
US

V. Phone/Fax

Practice location:
  • Phone: 801-747-8015
  • Fax:
Mailing address:
  • Phone: 801-747-8015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN BOWMAN
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 405-326-8004