Provider Demographics
NPI:1164883104
Name:ENSLOW, MARC (DMD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:ENSLOW
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 W TOWNE CENTER DR STE A2
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8697
Mailing Address - Country:US
Mailing Address - Phone:801-254-7003
Mailing Address - Fax:
Practice Address - Street 1:1685 W TOWNE CENTER DR STE A2
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8697
Practice Address - Country:US
Practice Address - Phone:801-254-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9823057-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program