Provider Demographics
NPI:1649424029
Name:BOYACK, MICHAEL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:G
Last Name:BOYACK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 S. STATE STREET
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097
Mailing Address - Country:US
Mailing Address - Phone:801-224-0222
Mailing Address - Fax:801-226-7560
Practice Address - Street 1:3451 S 5600 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-1301
Practice Address - Country:US
Practice Address - Phone:801-969-1400
Practice Address - Fax:801-969-1401
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51145561223X0400X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics