Provider Demographics
NPI:1497230734
Name:DVORAK, THERESA E (RD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:E
Last Name:DVORAK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 E FORTUNA DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-5616
Mailing Address - Country:US
Mailing Address - Phone:970-420-9338
Mailing Address - Fax:
Practice Address - Street 1:3334 E FORTUNA DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-5616
Practice Address - Country:US
Practice Address - Phone:970-420-9338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6317644-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered