Provider Demographics
NPI:1437252491
Name:STATE OF UTAH, DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:STATE OF UTAH, DEPARTMENT OF HEALTH
Other - Org Name:FAMILY DENTAL PLAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDWALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-538-6111
Mailing Address - Street 1:288 NORTH 1460 WEST
Mailing Address - Street 2:P.O. BOX 143107
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84114-3107
Mailing Address - Country:US
Mailing Address - Phone:801-538-6111
Mailing Address - Fax:
Practice Address - Street 1:SALT LAKE CLINIC - FAMILY DENTAL PLAN
Practice Address - Street 2:3195 SOUTH MAIN STREET, SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84114
Practice Address - Country:US
Practice Address - Phone:801-468-0342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========6026Medicaid