MEDICARE: BANSEH NAEIM DMD

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	1223G0001X	General Practice Dentistry	12804029-9923	UT

General Provider Information

NPI Number	:	1679216881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BANSEH NAEIM DMD

Provider Business Mailing Address
First Line	:	213 W CIVIC CENTER DR APT 466
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84070-1307
Country	:	US
Telephone Number	:	248-990-3270
Fax Number	:

Provider Business Practice Location Address
First Line	:	7069 S HIGHLAND DR STE 200
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-3731
Country	:	US
Telephone Number	:	801-292-0443
Fax Number	:

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

Provider Enumeration Date	:	04/15/2022
Last Update Date	:	04/15/2022

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