Healthcare Provider Details

I. General information

NPI: 1134366602
Provider Name (Legal Business Name): ROGER J ADAMS DMD, MS, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5373 GREEN ST SUITE 400
SALT LAKE CITY UT
84123-4680
US

IV. Provider business mailing address

669 ROCKY KNOLL LN
DRAPER UT
84020-7659
US

V. Phone/Fax

Practice location:
  • Phone: 801-313-7051
  • Fax: 801-290-5126
Mailing address:
  • Phone: 801-450-6040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number140656-9924
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: