Provider Demographics
NPI:1790593051
Name:12465 S FORT ST DRAPER DENTAL LLC
Entity type:Organization
Organization Name:12465 S FORT ST DRAPER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALLIS
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:ZURCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-550-5013
Mailing Address - Street 1:3757 E HERMES DR
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3337
Mailing Address - Country:US
Mailing Address - Phone:801-550-5013
Mailing Address - Fax:
Practice Address - Street 1:12465 S FORT ST STE 100
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8354
Practice Address - Country:US
Practice Address - Phone:801-576-1167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental