MEDICARE: UTAH WISDOM TEETH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	7359070	UT

General Provider Information

NPI Number	:	1568974434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH WISDOM TEETH, LLC

Provider Business Mailing Address
First Line	:	5406 W 11000 N STE 103-226
Second Line	:
City	:	HIGHLAND
State	:	UT
Zip	:	84003-8942
Country	:	US
Telephone Number	:	801-899-5512
Fax Number	:

Provider Business Practice Location Address
First Line	:	1030 E 11400 S STE 2A
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84094-6906
Country	:	US
Telephone Number	:	801-406-8670
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOHN JOSHUA SMITH
Credential	:	DDS
Telephone Number	:	801-694-8378

Provider Enumeration Date	:	10/31/2017
Last Update Date	:	10/31/2017

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