MEDICARE: DR. CLIFFORD G. SORENSEN DDS

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	1329799922	UT

General Provider Information

NPI Number	:	1679635858
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFFORD G. SORENSEN DDS

Provider Business Mailing Address
First Line	:	PO BOX 139
Second Line	:	7458 E. 1ST STREET
City	:	HUNTSVILLE
State	:	UT
Zip	:	84317-0139
Country	:	US
Telephone Number	:	801-643-1812
Fax Number	:

Provider Business Practice Location Address
First Line	:	7458 E FIRST ST
Second Line	:
City	:	HUNTSVILLE
State	:	UT
Zip	:	84317-9803
Country	:	US
Telephone Number	:	801-643-1812
Fax Number	:

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	09/04/2008

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