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General NPI Number Information
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NPI Number | 1043725799
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Entity Type | Organization
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Legal Business Name | GREATER ENDODONTICS LLC
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Dates
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Enumeration Date | 12/04/2017
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Last Update Date | 12/04/2017
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Provider Practice Location Address
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Address Line | 5334 SOUTH WOODROW STREET SUITE 201
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City | SALT LAKE CITY
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State | UT
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Zip | 84107
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Country | US
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Telephone | 801-268-3636
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Fax | 801-942-7652
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Provider Business Mailing Address
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Address Line | P.O. BOX 71277
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City | SALT LAKE CITY
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State | UT
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Zip | 84171
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Country | US
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Telephone | 801-268-3636
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Fax | 801-942-7652
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | RANDALL MADSEN
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Credential | DDS
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Telephone | 801-268-3636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 77525365
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 5639652
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License Number State | UT
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