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General NPI Number Information
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NPI Number | 1629841341
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Entity Type | Organization
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Legal Business Name | PLAIN CITY FAMILY DENTAL PLLC
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Dates
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Enumeration Date | 11/03/2023
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Last Update Date | 11/03/2023
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Provider Practice Location Address
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Address Line | 2384 N 4350 W
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City | PLAIN CITY
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State | UT
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Zip | 84404-9617
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Country | US
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Telephone | 801-948-0673
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Fax |
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Provider Business Mailing Address
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Address Line | 3968 W 5700 S
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City | ROY
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State | UT
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Zip | 84067-9176
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Country | US
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Telephone | 801-376-6494
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | PETER CHRISTIAN MORTENSON
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Credential | DDS
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Telephone | 801-948-0673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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