Healthcare Provider Details

I. General information

NPI: 1700129582
Provider Name (Legal Business Name): RICHARD BURTON SICKELSMITH D.V.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2013
Last Update Date: 03/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8576 S REDWOOD RD
WEST JORDAN UT
84088-9313
US

IV. Provider business mailing address

2632 COTTAGE LOOP
PARK CITY UT
84098-8256
US

V. Phone/Fax

Practice location:
  • Phone: 801-561-9595
  • Fax:
Mailing address:
  • Phone: 435-731-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5606688 - 2801
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5606688 - 8910
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: