MEDICARE: PLAIN CITY FAMILY DENTAL PLLC

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	:	1629841341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLAIN CITY FAMILY DENTAL PLLC

Provider Business Mailing Address
First Line	:	3968 W 5700 S
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-9176
Country	:	US
Telephone Number	:	801-376-6494
Fax Number	:

Provider Business Practice Location Address
First Line	:	2384 N 4350 W
Second Line	:
City	:	PLAIN CITY
State	:	UT
Zip	:	84404-9617
Country	:	US
Telephone Number	:	801-948-0673
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	PETER CHRISTIAN MORTENSON
Credential	:	DDS
Telephone Number	:	801-948-0673

Provider Enumeration Date	:	11/03/2023
Last Update Date	:	11/03/2023

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