Healthcare Provider Details

I. General information

NPI: 1740636570
Provider Name (Legal Business Name): MCDONOUGH ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6070 S 1300 E SUITE 202
SALT LAKE CITY UT
84121-6722
US

IV. Provider business mailing address

6070 S 1300 E SUITE 202
SALT LAKE CITY UT
84121-6722
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 Number6740566-9922
License Number StateUT

VIII. Authorized Official

Name: DR. DAVID ROY MCDONOUGH
Title or Position: OWNER
Credential: DDS, MSD
Phone: 801-266-2662