MEDICARE: STATE OF UTAH, DEPARTMENT OF HEALTH

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

General Provider Information

NPI Number	:	1437252491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF UTAH, DEPARTMENT OF HEALTH

Provider Business Mailing Address
First Line	:	288 NORTH 1460 WEST
Second Line	:	P.O. BOX 143107
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114-3107
Country	:	US
Telephone Number	:	801-538-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	SALT LAKE CLINIC - FAMILY DENTAL PLAN
Second Line	:	3195 SOUTH MAIN STREET, SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84114
Country	:	US
Telephone Number	:	801-468-0342
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. DAVID SUNDWALL
Credential	:	M.D.
Telephone Number	:	801-538-6111

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	08/22/2020

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