MEDICARE: TOOTH DOCTOR - CH, LLC

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	8813690-9922	UT

General Provider Information

NPI Number	:	1235643016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOOTH DOCTOR - CH, LLC

Provider Business Mailing Address
First Line	:	2180 E FORT UNION BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3148
Country	:	US
Telephone Number	:	801-944-4141
Fax Number	:

Provider Business Practice Location Address
First Line	:	2180 E FORT UNION BLVD
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3148
Country	:	US
Telephone Number	:	801-944-4141
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DEVIN J. ORVIN
Credential	:	DDS
Telephone Number	:	801-989-7803

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	11/30/2017

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