MEDICARE: TRIPLE CROWN DENTAL 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	261QD0000X	Dental Clinic/Center	9030705-8903	UT
2	261QD0000X	Dental Clinic/Center	9030705-9922	UT

General Provider Information

NPI Number	:	1730581919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIPLE CROWN DENTAL PLLC

Provider Business Mailing Address
First Line	:	2725 EAST PARLEYS WAY
Second Line	:	SUITE 150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109
Country	:	US
Telephone Number	:	801-875-0570
Fax Number	:	801-657-3745

Provider Business Practice Location Address
First Line	:	2725 E PARLEYS WAY
Second Line	:	SUITE 150
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1667
Country	:	US
Telephone Number	:	801-875-0570
Fax Number	:	801-657-3745

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	DR. TAUREAN TRAVAS SMITH
Credential	:	D.M.D.
Telephone Number	:	801-310-8244

Provider Enumeration Date	:	09/19/2014
Last Update Date	:	10/20/2016

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