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General NPI Number Information
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NPI Number | 1790593051
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Entity Type | Organization
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Legal Business Name | 12465 S FORT ST DRAPER DENTAL LLC
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Dates
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Enumeration Date | 12/19/2024
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Last Update Date | 12/19/2024
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Provider Practice Location Address
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Address Line | 12465 S FORT ST STE 100
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City | DRAPER
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State | UT
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Zip | 84020-8354
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Country | US
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Telephone | 801-576-1167
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Fax |
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Provider Business Mailing Address
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Address Line | 3757 E HERMES DR
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City | MILLCREEK
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State | UT
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Zip | 84124-3337
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Country | US
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Telephone | 801-550-5013
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. DALLIS JACOB ZURCHER
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Credential | DDS
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Telephone | 801-550-5013
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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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