Provider Demographics
NPI:1144022914
Name:MODERN DENTAL PROFESSIONALS - UTAH, PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS - UTAH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-955-1900
Mailing Address - Street 1:8415 DATAPOINT DR STE 1020
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3277
Mailing Address - Country:US
Mailing Address - Phone:210-929-2814
Mailing Address - Fax:210-615-3626
Practice Address - Street 1:370 E SOUTH TEMPLE STE 350
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1258
Practice Address - Country:US
Practice Address - Phone:801-320-9810
Practice Address - Fax:801-335-9409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN DENTAL PROFESSIONALS - UTAH, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty