MEDICARE: DR. MARK JAMES CALLAN 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	1223G0001X	General Practice Dentistry	141407-9921	UT

General Provider Information

NPI Number	:	1720022783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK JAMES CALLAN D.D.S.

Provider Business Mailing Address
First Line	:	261 GLEN DR
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2304
Country	:	US
Telephone Number	:	801-451-5664
Fax Number	:

Provider Business Practice Location Address
First Line	:	370 E SOUTH TEMPLE
Second Line	:	SUITE 220
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1206
Country	:	US
Telephone Number	:	801-355-8287
Fax Number	:

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

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	07/18/2012

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