MEDICARE: JEREMY RANCH DENTAL CENTER

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	1223G0001X	General Practice Dentistry	57294409922	UT

General Provider Information

NPI Number	:	1144338575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEREMY RANCH DENTAL CENTER

Provider Business Mailing Address
First Line	:	2700 HOMESTEAD RD
Second Line	:	SUITE # 130
City	:	PARK CITY
State	:	UT
Zip	:	84098-4857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 HOMESTEAD RD
Second Line	:	SUITE # 130
City	:	PARK CITY
State	:	UT
Zip	:	84098-4857
Country	:	US
Telephone Number	:	435-940-9900
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BENJAMIN RUSSELL
Credential	:	D.M.D.
Telephone Number	:	435-940-9900

Provider Enumeration Date	:	08/27/2006
Last Update Date	:	08/22/2020

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