=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780945667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID SANDBERG D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2012
-----------------------------------------------------
Last Update Date | 04/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1526 UTE BLVD STE 212
-----------------------------------------------------
City | PARK CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84098-7654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-615-8500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 993 S LAKE ST
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84105-1238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-560-2277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8325679-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------