Healthcare Provider Details

I. General information

NPI: 1811129919
Provider Name (Legal Business Name): MICHELLE KRISTIN MAAK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE KRISTIN MAAK DMD

II. Dates (important events)

Enumeration Date: 08/23/2009
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 S 900 E STE 100
SALT LAKE CITY UT
84121-2497
US

IV. Provider business mailing address

6268 S 900 E STE 100
SALT LAKE CITY UT
84121-2497
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-5117
  • Fax:
Mailing address:
  • Phone: 801-566-5117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number054597
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: