Provider Demographics
NPI:1437682002
Name:SALT LAKE DENTAL CARE
Entity Type:Organization
Organization Name:SALT LAKE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-938-8855
Mailing Address - Street 1:279 E 5900 S STE 202
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5425
Mailing Address - Country:US
Mailing Address - Phone:801-938-8855
Mailing Address - Fax:801-880-9832
Practice Address - Street 1:279 E 5900 S STE 202
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5425
Practice Address - Country:US
Practice Address - Phone:801-938-8855
Practice Address - Fax:801-880-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT59363461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty