Provider Demographics
NPI:1598564080
Name:ICON DENTISTRY OF UTAH LLC
Entity type:Organization
Organization Name:ICON DENTISTRY OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-318-8520
Mailing Address - Street 1:819 N 900 W
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-7701
Mailing Address - Country:US
Mailing Address - Phone:801-318-8520
Mailing Address - Fax:
Practice Address - Street 1:819 N 900 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7701
Practice Address - Country:US
Practice Address - Phone:801-318-8520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No292200000XLaboratoriesDental Laboratory