Organization
DHEW IND HLTH SVCS & MNTL HLTH SVCS
Active
Other names
U&O - Dental
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DELBERT GARY MARTIN RPH (CHIEF PHARMACIST)
(435) 725-6874
Entity
Organization
Contact information
Practice address
6822 E 1000 SOUTH, FORT DUCHESNE, UT 84026
(435) 722-5122
Mailing address
6822 E. 1000 SOUTH, FORT DUCHESNE, UT 84026
(435) 722-5122
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
—
—
1223E0200X
Endodontics
—
—
1223G0001X
General Practice Dentistry
—
—
1223P0300X
Periodontics
—
—
124Q00000X
Dental Hygienist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
700000000009
—
UT
01
—
AZ0522260
BLUE CROSS BLUE SHIELD
AZ
Enumeration date
06/26/2008
Last updated
04/04/2013
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