MEDICARE: NORTH DAVIS PEDIATRIC DENTISTRY 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1619764099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH DAVIS PEDIATRIC DENTISTRY LLC

Provider Business Mailing Address
First Line	:	1792 W 1700 S STE 101
Second Line	:
City	:	SYRACUSE
State	:	UT
Zip	:	84075-9650
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1792 W 1700 S STE 101
Second Line	:
City	:	SYRACUSE
State	:	UT
Zip	:	84075-9650
Country	:	US
Telephone Number	:	801-919-8880
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JASON HORGESHEIMER
Credential	:
Telephone Number	:	801-919-8880

Provider Enumeration Date	:	04/21/2025
Last Update Date	:	04/21/2025

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