=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588964340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAYSON FAMILY AND COSMETIC DENTISTRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2010
-----------------------------------------------------
Last Update Date | 10/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 S 500 W
-----------------------------------------------------
City | PAYSON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84651-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-465-7966
-----------------------------------------------------
Fax | 801-303-7055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2754 SAINT MARYS WAY
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84108-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-560-9757
-----------------------------------------------------
Fax | 801-303-7055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. KEVIN S CAHOON
-----------------------------------------------------
Credential | DDS, MBA
-----------------------------------------------------
Telephone | 801-560-9757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 1399149922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------