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General NPI Number Information
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NPI Number | 1407112469
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Entity Type | Organization
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Legal Business Name | MIDVALE MODERN DENTISTRY, LLP
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Dates
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Enumeration Date | 04/04/2012
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Last Update Date | 12/31/2013
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Provider Practice Location Address
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Address Line | 1144 EAST FORT UNION BOULEVARD
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City | MIDVALE
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State | UT
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Zip | 84047
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Country | US
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Telephone | 801-566-3118
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Fax | 801-561-1343
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Provider Business Mailing Address
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Address Line | 17000 RED HILL AVE
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City | IRVINE
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State | CA
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Zip | 92614-5626
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Country | US
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Telephone | 714-845-8890
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Fax | 949-474-1495
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Authorized Official
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Title or Position | DDS/OWNER
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Name | DR. ERIC JOHN SWENSEN
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Credential |
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Telephone | 801-566-3118
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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 |
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License Number State |
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