MEDICARE: MODERN DENTAL PROFESSIONALS - UTAH, PC

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

General Provider Information

NPI Number	:	1720485709
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN DENTAL PROFESSIONALS - UTAH, PC

Provider Business Mailing Address
First Line	:	4645 S 4000 W STE B
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84120-6250
Country	:	US
Telephone Number	:	801-955-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	4645 S 4000 W STE B
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84120-6250
Country	:	US
Telephone Number	:	801-955-1900
Fax Number	:	801-955-8300

Authorized Official
Title or Position	:	CREDENTIALING DIRECTOR
Name	:	LILIANA MARTINEZ
Credential	:
Telephone Number	:	949-308-9792

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	04/08/2024

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