Provider Demographics
NPI:1023040763
Name:GREGORY W EGBERT DDS MSD PC
Entity type:Organization
Organization Name:GREGORY W EGBERT DDS MSD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:801-265-1500
Mailing Address - Street 1:1250 E 3900 SO
Mailing Address - Street 2:STE 210
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1367
Mailing Address - Country:US
Mailing Address - Phone:801-265-1500
Mailing Address - Fax:801-265-1523
Practice Address - Street 1:1250 E 3900 SO
Practice Address - Street 2:STE 210
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84124-1367
Practice Address - Country:US
Practice Address - Phone:801-265-1500
Practice Address - Fax:801-265-1523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1435121223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528706087022Medicaid