MEDICARE: MICHAEL R. COTTAM MS DMD 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	1223P0221X	Pediatric Dentistry	8296939-9923

General Provider Information

NPI Number	:	1679823058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL R. COTTAM MS DMD PLLC

Provider Business Mailing Address
First Line	:	4775 W DAYBREAK PKWY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-5968
Country	:	US
Telephone Number	:	801-261-3178
Fax Number	:	801-268-1930

Provider Business Practice Location Address
First Line	:	4775 W DAYBREAK PKWY
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-5968
Country	:	US
Telephone Number	:	801-261-3178
Fax Number	:	801-268-1930

Authorized Official
Title or Position	:	DENTIST
Name	:	MICHAEL R COTTAM
Credential	:	DMD
Telephone Number	:	801-261-3178

Provider Enumeration Date	:	09/13/2012
Last Update Date	:	09/13/2012

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