Provider Demographics
NPI:1184755167
Name:SORENSON, TERRY R (DMD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:R
Last Name:SORENSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12569 S 2700 W STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7191
Mailing Address - Country:US
Mailing Address - Phone:801-254-7272
Mailing Address - Fax:801-254-6565
Practice Address - Street 1:12569 S 2700 W STE 100
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7191
Practice Address - Country:US
Practice Address - Phone:801-254-7272
Practice Address - Fax:801-254-6565
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3415461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice