Healthcare Provider Details

I. General information

NPI: 1780694885
Provider Name (Legal Business Name): SOUTHTOWN ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 10000 S SUITE 305
SANDY UT
84070
US

IV. Provider business mailing address

45 W 10000 S SUITE 305
SANDY UT
84070
US

V. Phone/Fax

Practice location:
  • Phone: 801-233-0503
  • Fax: 801-233-0593
Mailing address:
  • Phone: 801-233-0503
  • Fax: 801-233-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number55467
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. THOMAS MARK VAN DEN BERGHE
Title or Position: OWNER
Credential: DDS
Phone: 801-233-0503