MEDICARE: SNOW COUNTRY DENTAL CARE

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

General Provider Information

NPI Number	:	1841627460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SNOW COUNTRY DENTAL CARE

Provider Business Mailing Address
First Line	:	2680 E BRIDGEPORT AVE
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-5603
Country	:	US
Telephone Number	:	435-649-9492
Fax Number	:

Provider Business Practice Location Address
First Line	:	1729 SIDEWINDER DR STE 102
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7518
Country	:	US
Telephone Number	:	435-649-9492
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JR DETHORN
Credential	:
Telephone Number	:	435-649-9492

Provider Enumeration Date	:	09/27/2013
Last Update Date	:	09/27/2013

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Directions to “SNOW COUNTRY DENTAL CARE ” Practice Location

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