MEDICARE: DR. MICHELLE KRISTIN MAAK DMD

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	054597	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7372659-9924	OTHER	UT	LICENSE

General Provider Information

NPI Number	:	1811129919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE KRISTIN MAAK DMD

Provider Business Mailing Address
First Line	:	6268 S 900 E
Second Line	:	STE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:

Provider Business Practice Location Address
First Line	:	6268 S 900 E
Second Line	:	STE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:

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

Provider Enumeration Date	:	08/23/2009
Last Update Date	:	06/11/2019

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