Healthcare Provider Details

I. General information

NPI: 1205284247
Provider Name (Legal Business Name): WISDOM TEETH GUYS - TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S COOPER ST STE 105
ARLINGTON TX
76001-6752
US

IV. Provider business mailing address

5406 W 11000 N STE 103-226
HIGHLAND UT
84003-8942
US

V. Phone/Fax

Practice location:
  • Phone: 214-317-4039
  • Fax:
Mailing address:
  • Phone: 801-899-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22989
License Number StateTX

VIII. Authorized Official

Name: RYAN JOHNSON
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 702-299-5821