=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831721240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SG DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2020
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 SKYHAWK DR
-----------------------------------------------------
City | WENDOVER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84083-4501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-718-6881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3569 W 10305 S
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84095-8213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-665-7730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. JAMES SPENCER GRUBER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 435-665-7730
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------