Healthcare Provider Details

I. General information

NPI: 1922664556
Provider Name (Legal Business Name): SALT LAKE IMPLANTS AND PERIODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 05/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 S 700 E STE 8
SALT LAKE CITY UT
84107-2582
US

IV. Provider business mailing address

4010 S 700 E STE 8
SALT LAKE CITY UT
84107-2582
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-3519
  • Fax:
Mailing address:
  • Phone: 801-266-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: MARK MANGELSON
Title or Position: OWNER
Credential: DDS
Phone: 801-266-3519