MEDICARE: MCDONOUGH ORTHODONTICS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	6740566-9922	UT

General Provider Information

NPI Number	:	1740636570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCDONOUGH ORTHODONTICS

Provider Business Mailing Address
First Line	:	6070 S 1300 E
Second Line	:	SUITE 202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6722
Country	:	US
Telephone Number	:	801-266-2662
Fax Number	:	801-268-2009

Provider Business Practice Location Address
First Line	:	6070 S 1300 E
Second Line	:	SUITE 202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-6722
Country	:	US
Telephone Number	:	801-266-2662
Fax Number	:	801-268-2009

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID ROY MCDONOUGH
Credential	:	DDS, MSD
Telephone Number	:	801-266-2662

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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Directions to “MCDONOUGH ORTHODONTICS ” Practice Location

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