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1729 Sidewinder Dr. Ste 102 Park City UT 84060-7518 | |
| (435) 649-9492 | |
| (801) 692-9083 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 1729 Sidewinder Dr., Park City, Utah |
| Authorized Official Name and Position | Jacob Warner (CREDENTIALING MANAGER) |
| Authorized Official Contact | 8016911701 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 970309 Orem UT 84097-0309 Ph: (801) 691-1701 | 1729 Sidewinder Dr. Ste 102 Park City UT 84060-7518 Ph: (435) 649-9492 |
| NPI Number | 1669909511 |
|---|---|
| Provider Enumeration Date | 05/22/2017 |
| Last Update Date | 07/02/2021 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1669909511 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | 352590747 (Utah) | Primary |
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