Provider Demographics
NPI:1669590659
Name:POULSON, DANIEL STANFORD (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:STANFORD
Last Name:POULSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 E 4500 S STE 270
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4023
Mailing Address - Country:US
Mailing Address - Phone:801-278-8481
Mailing Address - Fax:801-278-3357
Practice Address - Street 1:2180 E 4500 S STE 270
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4023
Practice Address - Country:US
Practice Address - Phone:801-278-8481
Practice Address - Fax:801-278-3357
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT136941-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist