MEDICARE: DR WESLEY F TILLMANN DMD PC

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	122300000X	Dentist	7393738	UT

General Provider Information

NPI Number	:	1205286655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR WESLEY F TILLMANN DMD PC

Provider Business Mailing Address
First Line	:	5872 S 900 E STE 202
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1682
Country	:	US
Telephone Number	:	801-281-8433
Fax Number	:

Provider Business Practice Location Address
First Line	:	5872 S 900 E STE 202
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1682
Country	:	US
Telephone Number	:	801-281-8433
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MCLEAN BODDY
Credential	:
Telephone Number	:	801-281-8433

Provider Enumeration Date	:	06/16/2016
Last Update Date	:	06/16/2016

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