MEDICARE: TODD STEVEN VINCENT 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	122300000X	Dentist	00202233	CO
2	1223G0001X	General Practice Dentistry	33749	TX
3	1223G0001X	General Practice Dentistry	9236046-9922	UT

General Provider Information

NPI Number	:	1508272915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TODD STEVEN VINCENT DDS

Provider Business Mailing Address
First Line	:	1765 N TOWN EAST BLVD STE 111
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-4151
Country	:	US
Telephone Number	:	972-270-7210
Fax Number	:

Provider Business Practice Location Address
First Line	:	2114 S HIGHLAND DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2807
Country	:	US
Telephone Number	:	801-467-2345
Fax Number	:

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

Provider Enumeration Date	:	07/07/2014
Last Update Date	:	11/21/2019

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