=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073516688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS DEDECKER DDS, PC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2185 N 1700 W #204
-----------------------------------------------------
City | LAYTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84041-1154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-773-9790
-----------------------------------------------------
Fax | 801-773-9792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 447 E 700 N TWIN CREEK CIRCLE
-----------------------------------------------------
City | KAYSVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-544-2863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 1356659924
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------