MEDICARE: DR. CRAIG R. PROCTOR DDS

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	143618-9922	UT

General Provider Information

NPI Number	:	1952408536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG R. PROCTOR DDS

Provider Business Mailing Address
First Line	:	2936 HIGHLAND DR
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3582
Country	:	US
Telephone Number	:	801-486-2800
Fax Number	:	801-485-8188

Provider Business Practice Location Address
First Line	:	2936 HIGHLAND DR
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3582
Country	:	US
Telephone Number	:	801-486-2800
Fax Number	:	801-485-8188

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

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	07/08/2007

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