Provider Demographics
NPI:1740636570
Name:MCDONOUGH ORTHODONTICS
Entity type:Organization
Organization Name:MCDONOUGH ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:801-266-2662
Mailing Address - Street 1:6070 S 1300 E
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6722
Mailing Address - Country:US
Mailing Address - Phone:801-266-2662
Mailing Address - Fax:801-268-2009
Practice Address - Street 1:6070 S 1300 E
Practice Address - Street 2:SUITE 202
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6722
Practice Address - Country:US
Practice Address - Phone:801-266-2662
Practice Address - Fax:801-268-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6740566-99221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty