Provider Demographics
NPI:1689310948
Name:UTAH MODERN MEDICAL LLC
Entity Type:Organization
Organization Name:UTAH MODERN MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-414-2158
Mailing Address - Street 1:14839 S CANYON POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1489
Mailing Address - Country:US
Mailing Address - Phone:385-414-2158
Mailing Address - Fax:888-823-5887
Practice Address - Street 1:14839 S CANYON POINT ROAD
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-1489
Practice Address - Country:US
Practice Address - Phone:385-414-2158
Practice Address - Fax:888-823-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-10
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty