Healthcare Provider Details

I. General information

NPI: 1023040763
Provider Name (Legal Business Name): GREGORY W EGBERT DDS MSD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 SO STE 210
SLC UT
84124-1367
US

IV. Provider business mailing address

1250 E 3900 SO STE 210
SLC UT
84124-1367
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-1500
  • Fax: 801-265-1523
Mailing address:
  • Phone: 801-265-1500
  • Fax: 801-265-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number143512
License Number StateUT

VIII. Authorized Official

Name: GREGORY WILLIAM EGBERT
Title or Position: OWNER
Credential: DDS MSD
Phone: 801-265-1500