MEDICARE: MATTHEW CARMODY DDS

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	12558925-9924	UT

General Provider Information

NPI Number	:	1467914606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW CARMODY DDS

Provider Business Mailing Address
First Line	:	1452 E REDONDO AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3710
Country	:	US
Telephone Number	:	402-681-4101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4888 S HIGHLAND DR
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-6007
Country	:	US
Telephone Number	:	801-997-1137
Fax Number	:

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

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	06/20/2022

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