MEDICARE: DAN C. HENRY JR. MD

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	207Q00000X	Family Medicine Physician	1601211205	UT

General Provider Information

NPI Number	:	1871528018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAN C. HENRY JR. MD

Provider Business Mailing Address
First Line	:	2295 FOOTHILL DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84109-4000
Country	:	US
Telephone Number	:	801-486-3021
Fax Number	:	801-485-6339

Provider Business Practice Location Address
First Line	:	2295 FOOTHILL DR
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84109-4000
Country	:	US
Telephone Number	:	801-486-3021
Fax Number	:	801-485-6339

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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