MEDICARE: MOUNTAIN VIEW PEDIATRIC DENTISTRY OF NORTH SALT LAKE PC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1619327699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN VIEW PEDIATRIC DENTISTRY OF NORTH SALT LAKE PC

Provider Business Mailing Address
First Line	:	420 NORTH REDWOOD ROAD, UNIT D
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-2810
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 N REDWOOD RD UNIT D
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-2810
Country	:	US
Telephone Number	:	801-292-5437
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	CAMERON QUAYLE
Credential	:	DDS
Telephone Number	:	801-292-5437

Provider Enumeration Date	:	06/21/2016
Last Update Date	:	06/21/2016

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