MEDICARE: UTAH DENTAL HEALTH PROFESSIONALS, P.C.

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	:	1548010432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH DENTAL HEALTH PROFESSIONALS, P.C.

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	:	505-947-4253
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	HILLARY THULL
Credential	:
Telephone Number	:	217-540-8946

Provider Enumeration Date	:	03/25/2024
Last Update Date	:	03/25/2024

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