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2200 East 4500 South Suite 240 Salt Lake City UT 84117 | |
| (801) 278-3864 | |
| (801) 278-3868 |
| Full Name | |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 2200 East 4500 South, Salt Lake City, Utah |
| Authorized Official Name and Position | Charles C Wall (OWNER) |
| Authorized Official Contact | 8012783864 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
2200 East 4500 South Suite 240 Salt Lake City UT 84117 Ph: (801) 278-3864 | 2200 East 4500 South Suite 240 Salt Lake City UT 84117 Ph: (801) 278-3864 |
| NPI Number | 1306060306 |
|---|---|
| Provider Enumeration Date | 04/12/2007 |
| Last Update Date | 07/22/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1306060306 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 51343669922 (Utah) | Primary |
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