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General NPI Number Information
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NPI Number | 1679055081
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Entity Type | Organization
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Legal Business Name | SMART SMILES UTAH
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Dates
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Enumeration Date | 08/31/2018
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Last Update Date | 08/31/2018
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Provider Practice Location Address
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Address Line | 10597 S BEACH COMBER WAY
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City | SOUTH JORDAN
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State | UT
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Zip | 84009-6132
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Country | US
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Telephone | 801-649-4222
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Fax |
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Provider Business Mailing Address
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Address Line | 10597 S BEACH COMBER WAY
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City | SOUTH JORDAN
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State | UT
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Zip | 84009-6132
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Country | US
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Telephone | 801-649-4222
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TANNER M CLARK
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Credential | DMD
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Telephone | 801-649-4222
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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 | 9860439-9921
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License Number State | UT
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