Healthcare Provider Details

I. General information

NPI: 1265984660
Provider Name (Legal Business Name): ADVANCED DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 W HIGHWAY 40
VERNAL UT
84078-2925
US

IV. Provider business mailing address

1272 W HIGHWAY 40
VERNAL UT
84078-2925
US

V. Phone/Fax

Practice location:
  • Phone: 435-781-0660
  • Fax:
Mailing address:
  • Phone: 435-781-0660
  • Fax: 435-781-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6712357-9923
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number6712357-9923
License Number StateUT

VIII. Authorized Official

Name: TYLER SHINER
Title or Position: PRESIDENT
Credential: DDS
Phone: 435-828-4099