=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750836839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEVIER VALLEY DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2016
-----------------------------------------------------
Last Update Date | 08/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 46 W 100 N
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84701-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-893-2190
-----------------------------------------------------
Fax | 435-893-2191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 46 W 100 N
-----------------------------------------------------
City | RICHFIELD
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84701-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-893-2190
-----------------------------------------------------
Fax | 435-893-2191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | TODD PAUL LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 435-893-2190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 322871-9923
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------