=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134052939
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLPD HERRIMAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2026
-----------------------------------------------------
Last Update Date | 06/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5532 MAIN ST STE 220
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-463-1900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5532 MAIN ST STE 220
-----------------------------------------------------
City | HERRIMAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DAVID GUSTAFSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-463-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------