Healthcare Provider Details

I. General information

NPI: 1538674056
Provider Name (Legal Business Name): ASHLEY GRIMM DENNIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1792 W 1700 S
SYRACUSE UT
84075-9645
US

IV. Provider business mailing address

1792 W 1700 S
SYRACUSE UT
84075-9645
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax:
Mailing address:
  • Phone: 801-773-8644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11149871-1205
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: