Healthcare Provider Details

I. General information

NPI: 1467373449
Provider Name (Legal Business Name): UTAH DENTAL ANESTHESIA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 W 950 N STE 102
OREM UT
84057-4171
US

IV. Provider business mailing address

1310 S VISTA AVE SUITE 21
BOISE ID
83705
US

V. Phone/Fax

Practice location:
  • Phone: 208-559-5518
  • Fax:
Mailing address:
  • Phone: 208-559-5518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: DR. JAKE WOOD
Title or Position: OWNER
Credential: DMD, MPH
Phone: 208-559-5518