Basic Information
| Provider Information | |||||||||
| NPI: | 1720592421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAUTER | ||||||||
| FirstName: | DENVER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 980 S 500 W STE 1 | ||||||||
| Address2: | |||||||||
| City: | BRIGHAM CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843023094 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 980 S 500 W STE 1 | ||||||||
| Address2: | |||||||||
| City: | BRIGHAM CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843023094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357238276 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2017 | ||||||||
| LastUpdateDate: | 11/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 7671028-9920 | UT | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 7671028-9920 | 01 | UT | PROFESSIONAL LICENSING | OTHER |