Provider Demographics
NPI:1720022783
Name:CALLAN, MARK JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JAMES
Last Name:CALLAN
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 1:261 GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2304
Mailing Address - Country:US
Mailing Address - Phone:801-451-5664
Mailing Address - Fax:
Practice Address - Street 1:370 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 220
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1206
Practice Address - Country:US
Practice Address - Phone:801-355-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141407-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice