Provider Demographics
NPI:1679055081
Name:SMART SMILES UTAH
Entity type:Organization
Organization Name:SMART SMILES UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-649-4222
Mailing Address - Street 1:10597 S BEACH COMBER WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-6132
Mailing Address - Country:US
Mailing Address - Phone:801-649-4222
Mailing Address - Fax:
Practice Address - Street 1:10597 S BEACH COMBER WAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-6132
Practice Address - Country:US
Practice Address - Phone:801-649-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9860439-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9860439-9921Medicaid