Healthcare Provider Details

I. General information

NPI: 1508014127
Provider Name (Legal Business Name): PETER E. PAULOS, DDS, MS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6287 S REDWOOD RD SUITE 202
SALT LAKE CITY UT
84123-6634
US

IV. Provider business mailing address

6287 S REDWOOD RD SUITE 202
SALT LAKE CITY UT
84123-6634
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-3777
  • Fax: 801-262-5356
Mailing address:
  • Phone: 801-262-3777
  • Fax: 801-262-5356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number132585
License Number StateUT

VIII. Authorized Official

Name: DR. PETER E PAULOS
Title or Position: PRESIDENT
Credential: DDS, MS
Phone: 801-262-3777