MEDICARE: CLIFFORD DONALD DAINES D D S

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	143596-9922	UT

General Provider Information

NPI Number	:	1407964513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLIFFORD DONALD DAINES D D S

Provider Business Mailing Address
First Line	:	5974 FASHION POINT DR
Second Line	:	SUITE 230
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4699
Country	:	US
Telephone Number	:	801-621-8440
Fax Number	:	801-627-9063

Provider Business Practice Location Address
First Line	:	5974 FASHION POINT DR
Second Line	:	SUITE 230
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4699
Country	:	US
Telephone Number	:	801-621-8440
Fax Number	:	801-627-9063

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	07/08/2007

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