Provider Demographics
NPI:1558714550
Name:CD OREM LLC
Entity Type:Organization
Organization Name:CD OREM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-310-1916
Mailing Address - Street 1:1221 S 1840 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5978
Mailing Address - Country:US
Mailing Address - Phone:801-310-1916
Mailing Address - Fax:
Practice Address - Street 1:1221 S 1840 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5978
Practice Address - Country:US
Practice Address - Phone:801-310-1916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49369511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty