Healthcare Provider Details

I. General information

NPI: 1881731487
Provider Name (Legal Business Name): KEITH D. SONNTAG D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 E 4500 S SUITE #280
SALT LAKE CITY UT
84117-4434
US

IV. Provider business mailing address

2180 E 4500 S SUITE #280
SALT LAKE CITY UT
84117-4434
US

V. Phone/Fax

Practice location:
  • Phone: 801-274-6900
  • Fax: 801-274-6903
Mailing address:
  • Phone: 801-274-6900
  • Fax: 801-274-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number952942359922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: