Provider Demographics
NPI:1548915309
Name:FT. UNION DENTAL MANAGEMENT
Entity type:Organization
Organization Name:FT. UNION DENTAL MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:SEGO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-676-8100
Mailing Address - Street 1:1275 E. FORT UNION BLVD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1884
Mailing Address - Country:US
Mailing Address - Phone:801-676-8100
Mailing Address - Fax:801-871-5117
Practice Address - Street 1:1275 E. FORT UNION BLVD.
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84047-1884
Practice Address - Country:US
Practice Address - Phone:801-676-8100
Practice Address - Fax:801-871-5117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty