MEDICARE: DR. IVAN DARRELL VOORHEES D. D. S

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	122300000X	Dentist	137260	UT

General Provider Information

NPI Number	:	1669502258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN DARRELL VOORHEES D. D. S

Provider Business Mailing Address
First Line	:	8490 SCOTTISH DR
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-2143
Country	:	US
Telephone Number	:	801-942-0146
Fax Number	:

Provider Business Practice Location Address
First Line	:	1343 FORT UNION BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2859
Country	:	US
Telephone Number	:	801-943-3661
Fax Number	:	801-943-3621

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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