| NPI | 1982721114 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LAMONA MARIE FULLMER Owner 801-227-5080 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 5672963-0160) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 5672963-0160) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2020-08-22 |