Provider Demographics
NPI:1205454113
Name:HARMON, DYLAN LANE (DMD)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:LANE
Last Name:HARMON
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 1:1750 N 1780 E
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2192
Mailing Address - Country:US
Mailing Address - Phone:435-890-0379
Mailing Address - Fax:
Practice Address - Street 1:1445 N 400 E # 3A
Practice Address - Street 2:
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7564
Practice Address - Country:US
Practice Address - Phone:435-363-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11769010-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11769010-8903OtherUTAH DOPL
UT11769010-9922OtherUTAH DOPL