MEDICARE: PROVO PREMIER DENTAL GROUP PLLC

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	332BC3200X	Customized Equipment (DME)
2	122300000X	Dentist

General Provider Information

NPI Number	:	1396490314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVO PREMIER DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	247 W 2230 N STE 101
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-7582
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 N 500 W STE 204
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84601-1597
Country	:	US
Telephone Number	:	801-374-2182
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID SMITH
Credential	:	DDS
Telephone Number	:	801-375-1414

Provider Enumeration Date	:	02/17/2022
Last Update Date	:	04/23/2024

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