MEDICARE: ST. GEORGE KIDS DENTAL AT SNOW CANYON

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	8982123	UT

General Provider Information

NPI Number	:	1639667801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. GEORGE KIDS DENTAL AT SNOW CANYON

Provider Business Mailing Address
First Line	:	1100 CANYON VIEW DR STE A
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5672
Country	:	US
Telephone Number	:	435-673-3490
Fax Number	:	435-627-9954

Provider Business Practice Location Address
First Line	:	1100 CANYON VIEW DR STE A
Second Line	:
City	:	SANTA CLARA
State	:	UT
Zip	:	84765-5672
Country	:	US
Telephone Number	:	435-673-3490
Fax Number	:	435-627-9954

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JEFFREY WESTON HIGBEE
Credential	:	DMD
Telephone Number	:	435-590-7014

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	10/07/2020

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