Healthcare Provider Details

I. General information

NPI: 1235977240
Provider Name (Legal Business Name): PROFESSIONAL DENTAL SLC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 W 700 N STE A-1
SALT LAKE CITY UT
84116-1903
US

IV. Provider business mailing address

PO BOX 1806
OREM UT
84059-1806
US

V. Phone/Fax

Practice location:
  • Phone: 801-785-8000
  • Fax: 801-785-4030
Mailing address:
  • Phone: 801-785-8000
  • Fax: 801-785-4030

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: MR. ROBERT D HACK
Title or Position: OWNER
Credential:
Phone: 801-636-0110