Provider Demographics
NPI:1821028861
Name:HENTISH, ROMAN D (DC)
Entity Type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:D
Last Name:HENTISH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8844 S 280 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2343
Mailing Address - Country:US
Mailing Address - Phone:702-281-6847
Mailing Address - Fax:
Practice Address - Street 1:1972 W 5400 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-1459
Practice Address - Country:US
Practice Address - Phone:702-281-6847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01172111NN1001X
UT5578639-1202111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005776104Medicare ID - Type Unspecified
V01316Medicare UPIN
NV102022Medicare ID - Type Unspecified