MEDICARE: CLINTON OLIVER SORENSEN 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	80174279922	UT
2	1223G0001X	General Practice Dentistry	27343	TX

General Provider Information

NPI Number	:	1760767230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON OLIVER SORENSEN D.D.S.

Provider Business Mailing Address
First Line	:	1670 E ROYCROFT PL APT A
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2588
Country	:	US
Telephone Number	:	801-808-2061
Fax Number	:

Provider Business Practice Location Address
First Line	:	2725 E PARLEYS WAY STE 150
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1659
Country	:	US
Telephone Number	:	801-808-2061
Fax Number	:

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

Provider Enumeration Date	:	10/17/2011
Last Update Date	:	02/08/2018

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