Provider Demographics
NPI:1457911513
Name:DASTRUP, SAMUEL
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:DASTRUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 S 540 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4043
Mailing Address - Country:US
Mailing Address - Phone:801-821-8982
Mailing Address - Fax:
Practice Address - Street 1:1377 E 3900 S STE 202
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1495
Practice Address - Country:US
Practice Address - Phone:801-278-2817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11262405-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist