MEDICARE: LCR DENTAL ROSE PARK 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	122300000X	Dentist	6331945-9922	UT

General Provider Information

NPI Number	:	1558759514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LCR DENTAL ROSE PARK LLC

Provider Business Mailing Address
First Line	:	2215 S PRESTON ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1409 W 1000 N
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84116-1605
Country	:	US
Telephone Number	:	801-532-1402
Fax Number	:

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

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	12/29/2014

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