Healthcare Provider Details

I. General information

NPI: 1124228168
Provider Name (Legal Business Name): SCOTT BRYAN HAIR D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 E SOUTH TEMPLE SUITE 126
SALT LAKE CITY UT
84102-1013
US

IV. Provider business mailing address

420 E SOUTH TEMPLE STE 220
SALT LAKE CITY UT
84111-1329
US

V. Phone/Fax

Practice location:
  • Phone: 801-533-0200
  • Fax: 801-596-7164
Mailing address:
  • Phone: 801-533-0200
  • Fax: 801-596-7164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number144299-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: