=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003266057
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOYD BANDY D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 06/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 N 400 E
-----------------------------------------------------
City | BEAVER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84713-7710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-630-9755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1298 N WILLOWBROOK
-----------------------------------------------------
City | SARATOGA SPRINGS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84045-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-630-9755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9829784-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------