MEDICARE: PROFESSIONAL DENTAL WEST VALLEY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	124Q00000X	Dental Hygienist
3	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1457133779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL WEST VALLEY LLC

Provider Business Mailing Address
First Line	:	PO BOX 1806
Second Line	:
City	:	OREM
State	:	UT
Zip	:	84059-1806
Country	:	US
Telephone Number	:	801-785-8000
Fax Number	:	801-785-4030

Provider Business Practice Location Address
First Line	:	3601 S 2700 W
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84119-3746
Country	:	US
Telephone Number	:	801-785-8000
Fax Number	:	801-785-4030

Authorized Official
Title or Position	:	OWNER
Name	:	ROBERT D HACK
Credential	:
Telephone Number	:	801-636-0110

Provider Enumeration Date	:	10/20/2023
Last Update Date	:	02/07/2024

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