=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962892653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PDC HIGHLAND PARK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2015
-----------------------------------------------------
Last Update Date | 02/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3098 S HIGHLAND DR STE 400
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-484-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3098 S HIGHLAND DR STE 400
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-3618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-484-1032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | RHET SCHERSCHLIGT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-484-1032
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 378380-9922
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------