=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144022914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN DENTAL PROFESSIONALS - UTAH, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2025
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 370 E SOUTH TEMPLE STE 350
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84111-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-320-9810
-----------------------------------------------------
Fax | 801-335-9409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8415 DATAPOINT DR STE 1020
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3277
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-929-2814
-----------------------------------------------------
Fax | 210-615-3626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GREGORY SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-955-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------