=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073684338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLIFFORD OWEN SORENSEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 S STATE ST SUITE C
-----------------------------------------------------
City | CLEARFIELD
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84015-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-773-2252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1063 S 2450 W
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84075-7072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-774-9634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 143121
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------