Healthcare Provider Details

I. General information

NPI: 1720514870
Provider Name (Legal Business Name): MARGARET ELEANOR BRIDGET LISKUTIN D.M.D., M.S., M.B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S WAKARA WAY
SALT LAKE CITY UT
84108-1213
US

IV. Provider business mailing address

530 S WAKARA WAY
SALT LAKE CITY UT
84108-1213
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-6453
  • Fax:
Mailing address:
  • Phone: 801-587-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019031704
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13965835-8903
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: