Provider Demographics
NPI:1447004270
Name:SALT CITY ORTHODONTICS
Entity type:Organization
Organization Name:SALT CITY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:HILLSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-900-4748
Mailing Address - Street 1:11962 S ANTHEM PARK BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5692
Mailing Address - Country:US
Mailing Address - Phone:801-900-4748
Mailing Address - Fax:
Practice Address - Street 1:11962 S ANTHEM PARK BLVD STE 150
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5692
Practice Address - Country:US
Practice Address - Phone:801-900-4748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty