MEDICARE: FT. UNION DENTAL MANAGEMENT

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	:	1548915309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FT. UNION DENTAL MANAGEMENT

Provider Business Mailing Address
First Line	:	1275 E. FORT UNION BLVD.
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84047-1884
Country	:	US
Telephone Number	:	801-676-8100
Fax Number	:	801-871-5117

Provider Business Practice Location Address
First Line	:	1275 E. FORT UNION BLVD.
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84047-1884
Country	:	US
Telephone Number	:	801-676-8100
Fax Number	:	801-871-5117

Authorized Official
Title or Position	:	MEMBER/DENTIST
Name	:	ERNEST ADAM SEGO
Credential	:	DMD
Telephone Number	:	801-676-8100

Provider Enumeration Date	:	02/19/2022
Last Update Date	:	02/19/2022

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