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General NPI Number Information
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NPI Number | 1205203981
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Entity Type | Organization
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Legal Business Name | SUGAR HOUSE DENTAL CARE
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Dates
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Enumeration Date | 08/28/2015
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Last Update Date | 08/28/2015
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Provider Practice Location Address
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Address Line | 2114 S HIGHLAND DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84106-2807
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Country | US
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Telephone | 540-419-9422
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Fax |
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Provider Business Mailing Address
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Address Line | 3821 EAGLE RIDGE CT
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City | HAMPSTEAD
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State | MD
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Zip | 21074-1360
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Country | US
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Telephone | 410-804-2709
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE ASSISTANT
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Name | ANN MARIE WILSON
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Credential |
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Telephone | 540-419-9422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9187494-9921
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License Number State | UT
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