MEDICARE: ALLEN-TAINTOR DERMATOLOGY 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	207NS0135X	Procedural Dermatology Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1578229233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEN-TAINTOR DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	3860 JACKSON AVE STE 2
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:	801-627-0515
Fax Number	:	801-627-0517

Provider Business Practice Location Address
First Line	:	3860 JACKSON AVE STE 2
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:	801-627-0515
Fax Number	:	801-627-0517

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DIANE W CHRISTENSEN
Credential	:
Telephone Number	:	801-627-0515

Provider Enumeration Date	:	11/16/2021
Last Update Date	:	11/16/2021

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