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1953 W. California Ave Salt Lake City UT 84104 | |
| (801) 886-9341 | |
| (801) 886-1786 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 1953 W. California Ave, Salt Lake City, Utah |
| Authorized Official Name and Position | Angie Breeze (OFFICE MANAGER) |
| Authorized Official Contact | 8018869341 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 271069 Salt Lake City UT 84127-1069 Ph: (801) 886-9341 | 1953 W. California Ave Salt Lake City UT 84104 Ph: (801) 886-9341 |
| NPI Number | 1912014234 |
|---|---|
| Provider Enumeration Date | 08/23/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912014234 | NPI | - | NPPES |
| 545764459023 | Medicaid | UT |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 143681-9922 (Utah) | Primary |
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