=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114717808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BSOMM DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1662 W 9000 S
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-9233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-255-6581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1662 W 9000 S
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-9233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-255-6581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FRONT OFFICE
-----------------------------------------------------
Name | TIANA ROPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-255-6581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------