Basic Information
Provider Information | |||||||||
NPI: | 1730647330 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SALT LAKE MODERN DENTISTRY, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17000 RED HILL AVE | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926145626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1028 E 2100 S STE 3 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841063096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014386355 | ||||||||
FaxNumber: | 8013865639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2019 | ||||||||
LastUpdateDate: | 03/04/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURR | ||||||||
AuthorizedOfficialFirstName: | ADAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8014386355 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.