MEDICARE: BISHOP FAMILY DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	305R00000X	Preferred Provider Organization	78978139922	UT

General Provider Information

NPI Number	:	1023483252
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BISHOP FAMILY DENTAL

Provider Business Mailing Address
First Line	:	2120 E 3900 S
Second Line	:	SUITE 102
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1771
Country	:	US
Telephone Number	:	801-274-2500
Fax Number	:	801-274-0590

Provider Business Practice Location Address
First Line	:	2120 E 3900 S
Second Line	:	SUITE 102
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1771
Country	:	US
Telephone Number	:	801-274-2500
Fax Number	:	801-274-0590

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DANIEL BISHOP
Credential	:	DMD
Telephone Number	:	801-274-2500

Provider Enumeration Date	:	12/14/2015
Last Update Date	:	12/14/2015

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Directions to “BISHOP FAMILY DENTAL ” Practice Location

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