Healthcare Provider Details

I. General information

NPI: 1659009348
Provider Name (Legal Business Name): WISDOM TEETH NOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 S FASHION BLVD STE 195
MURRAY UT
84107-6159
US

IV. Provider business mailing address

PO BOX 900421
SANDY UT
84090-0421
US

V. Phone/Fax

Practice location:
  • Phone: 801-983-6802
  • Fax: 801-983-6803
Mailing address:
  • Phone: 801-879-1048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK ALLEN
Title or Position: OWNER
Credential:
Phone: 801-879-1048