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General NPI Number Information
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NPI Number | 1144605403
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Entity Type | Individual
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Provider Name | SHAD B MACKERT D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 07/28/2015
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Last Update Date | 09/19/2023
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Provider Practice Location Address
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Address Line | 12459 S 300 E STE 202
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City | DRAPER
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State | UT
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Zip | 84020-1899
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Country | US
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Telephone | 385-430-1200
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Fax |
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Provider Business Mailing Address
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Address Line | 12459 S 300 E STE 202
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City | DRAPER
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State | UT
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Zip | 84020-1899
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Country | US
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Telephone | 854-301-2003
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 10220776-8903
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 2901021479
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901021479
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License Number State | MI
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