Provider Demographics
NPI:1689635799
Name:DERMATOLOGY CENTER OF SALT LAKE INC.
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF SALT LAKE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:D
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-567-1400
Mailing Address - Street 1:7396 UNION PARK AVE
Mailing Address - Street 2:#201
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6700
Mailing Address - Country:US
Mailing Address - Phone:801-567-1400
Mailing Address - Fax:801-567-1777
Practice Address - Street 1:7396 UNION PARK AVE
Practice Address - Street 2:#201
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-6700
Practice Address - Country:US
Practice Address - Phone:801-567-1400
Practice Address - Fax:801-567-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT266561-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQM0000046926OtherALTIUS
UT528986681031Medicaid
UT52898668108001OtherBLUE SHIELD
107007222102OtherIHC
UTF77800Medicare UPIN
107007222102OtherIHC