MEDICARE: DR. LAURA PROVINE 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	122300000X	Dentist	9070494-9922	UT
2	122300000X	Dentist	9070494-8903	UT

General Provider Information

NPI Number	:	1912311879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA PROVINE DMD

Provider Business Mailing Address
First Line	:	3191 S VALLEY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-4274
Country	:	US
Telephone Number	:	801-463-6657
Fax Number	:

Provider Business Practice Location Address
First Line	:	3191 S VALLEY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-4274
Country	:	US
Telephone Number	:	801-463-6657
Fax Number	:

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

Provider Enumeration Date	:	06/18/2014
Last Update Date	:	06/18/2014

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Directions to “ DR. LAURA PROVINE DMD” Practice Location

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