Provider Demographics
NPI:1659591238
Name:MCDONOUGH, MARK J (DDS MSD PC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:MCDONOUGH
Suffix:
Gender:M
Credentials:DDS MSD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6070 SOUTH 1300 EAST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6724
Mailing Address - Country:US
Mailing Address - Phone:801-266-2662
Mailing Address - Fax:801-268-2009
Practice Address - Street 1:6070 SOUTH 1300 EAST
Practice Address - Street 2:SUITE 202
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6724
Practice Address - Country:US
Practice Address - Phone:801-266-2662
Practice Address - Fax:801-268-2009
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1375041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics