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General NPI Number Information
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NPI Number | 1235323932
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Entity Type | Organization
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Legal Business Name | COMFORT FAMILY DENTAL OF SOUTH OGDEN, LLC
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 09/05/2007
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Provider Practice Location Address
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Address Line | 5685 S 1475 E SUITE 2A
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City | SOUTH OGDEN
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State | UT
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Zip | 84403-4716
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Country | US
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Telephone | 801-475-0509
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Fax | 801-475-0136
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Provider Business Mailing Address
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Address Line | 5685 S 1475 E SUITE 2A
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City | SOUTH OGDEN
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State | UT
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Zip | 84403-4716
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Country | US
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Telephone | 801-475-0509
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Fax | 801-475-0136
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Authorized Official
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Title or Position | MANAGING DOCTOR
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Name | DR. PAUL A MACKLEY
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Credential | DDS
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Telephone | 801-782-6681
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 144024
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License Number State | UT
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