Healthcare Provider Details

I. General information

NPI: 1972100295
Provider Name (Legal Business Name): RILEY HUNSAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10654 S RIVER HEIGHTS DR
SOUTH JORDAN UT
84095-5522
US

IV. Provider business mailing address

5017 W LONDON BAY DR
RIVERTON UT
84096-1900
US

V. Phone/Fax

Practice location:
  • Phone: 801-472-7919
  • Fax:
Mailing address:
  • Phone: 801-472-7919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11677059-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: