MEDICARE: LCR DENTAL SUGAR HOUSE

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1518478742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LCR DENTAL SUGAR HOUSE

Provider Business Mailing Address
First Line	:	1409 W 1000 N
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2068 S 2100 E SUITE #A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108
Country	:	US
Telephone Number	:	801-532-1402
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	LAWRENCE CLARK ROMNEY
Credential	:	DMD
Telephone Number	:	801-541-7787

Provider Enumeration Date	:	10/16/2017
Last Update Date	:	10/16/2017

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Directions to “LCR DENTAL SUGAR HOUSE ” Practice Location

Language	Start Address	Practice Location

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