MEDICARE: SALT LAKE MOBILE DENTAL 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	:	1588334387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT LAKE MOBILE DENTAL LLC

Provider Business Mailing Address
First Line	:	6315 S COBBLECREST RD
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84121-2254
Country	:	US
Telephone Number	:	801-550-5013
Fax Number	:

Provider Business Practice Location Address
First Line	:	622 E 4500 S STE 201
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-2922
Country	:	US
Telephone Number	:	801-477-6333
Fax Number	:

Authorized Official
Title or Position	:	OWNER / DENTIST
Name	:	DR. DALLIS J ZURCHER
Credential	:	DDS
Telephone Number	:	801-550-5013

Provider Enumeration Date	:	09/14/2021
Last Update Date	:	09/14/2021

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