MEDICARE: LAKE MOUNTAIN DENTAL EAGLE MOUNTAIN LLC

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	:	1518641083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE MOUNTAIN DENTAL EAGLE MOUNTAIN LLC

Provider Business Mailing Address
First Line	:	4342 E PONY EXPRESS PKWY STE 100
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-5773
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4342 E PONY EXPRESS PKWY STE 100
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-5773
Country	:	US
Telephone Number	:	801-830-4486
Fax Number	:

Authorized Official
Title or Position	:	ADMIN
Name	:	CADEN CADEN
Credential	:
Telephone Number	:	801-830-4486

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	06/14/2023

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