Healthcare Provider Details

I. General information

NPI: 1659591238
Provider Name (Legal Business Name): MARK J MCDONOUGH DDS MSD PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 SOUTH 1300 EAST SUITE 202
SALT LAKE CITY UT
84121-6724
US

IV. Provider business mailing address

6070 SOUTH 1300 EAST SUITE 202
SALT LAKE CITY UT
84121-6724
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-2662
  • Fax: 801-268-2009
Mailing address:
  • Phone: 801-266-2662
  • Fax: 801-268-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number137504
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: