MEDICARE: PROFESSIONAL DENTAL SARATOGA 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1528838596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL SARATOGA 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	:	1314 N REDWOOD RD STE 102
Second Line	:
City	:	SARATOGA SPRINGS
State	:	UT
Zip	:	84045-4704
Country	:	US
Telephone Number	:	801-768-0440
Fax Number	:	801-785-4030

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ROBERT D HACK
Credential	:
Telephone Number	:	801-785-8000

Provider Enumeration Date	:	01/02/2024
Last Update Date	:	01/02/2024

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