Healthcare Provider Details

I. General information

NPI: 1356306872
Provider Name (Legal Business Name): MICHAEL C TEW D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 W 7800 S #200
WEST JORDAN UT
84088-4314
US

IV. Provider business mailing address

3855 W 7800 S #200
WEST JORDAN UT
84088-4314
US

V. Phone/Fax

Practice location:
  • Phone: 801-282-1802
  • Fax: 801-282-6244
Mailing address:
  • Phone: 801-282-1802
  • Fax: 801-282-6244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5352062
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: