MEDICARE: MR. RYAN GEORGE BOTT 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	6264440-9922	UT

General Provider Information

NPI Number	:	1871661801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN GEORGE BOTT D.D.S.

Provider Business Mailing Address
First Line	:	2852 W 4700 S
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118-2100
Country	:	US
Telephone Number	:	801-968-9147
Fax Number	:	801-966-2932

Provider Business Practice Location Address
First Line	:	2852 W 4700 S
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84118-2100
Country	:	US
Telephone Number	:	801-968-9147
Fax Number	:	801-966-2932

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

Provider Enumeration Date	:	11/30/2006
Last Update Date	:	07/08/2007

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