MEDICARE: BIG SMILES UTAH P.C.

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	9345989-9921	UT

General Provider Information

NPI Number	:	1275912040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG SMILES UTAH P.C.

Provider Business Mailing Address
First Line	:	33533 W 12 MILE RD
Second Line	:	SUITE 150
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-3354
Country	:	US
Telephone Number	:	888-833-8441
Fax Number	:	888-330-4331

Provider Business Practice Location Address
First Line	:	2825 E COTTONWOOD PKWY
Second Line	:	SUITE 500
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-7055
Country	:	US
Telephone Number	:	888-833-8441
Fax Number	:	888-330-4331

Authorized Official
Title or Position	:	DENTAL DIRECTOR
Name	:	ELLIOT SCHLANG
Credential	:	DDS
Telephone Number	:	888-833-8441

Provider Enumeration Date	:	05/26/2015
Last Update Date	:	05/26/2015

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