Healthcare Provider Details

I. General information

NPI: 1255364352
Provider Name (Legal Business Name): MICHAEL L WASUITA DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N FAIRFIELD RD
LAYTON UT
84041
US

IV. Provider business mailing address

525 N FAIRFIELD RD
LAYTON UT
84041
US

V. Phone/Fax

Practice location:
  • Phone: 801-546-1012
  • Fax: 801-546-2498
Mailing address:
  • Phone: 801-546-1012
  • Fax: 801-546-2498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1396499921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: