Healthcare Provider Details

I. General information

NPI: 1609325091
Provider Name (Legal Business Name): WS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 N 400 W #A4
OREM UT
84057-1909
US

IV. Provider business mailing address

167 N 400 W #A4
OREM UT
84057-1909
US

V. Phone/Fax

Practice location:
  • Phone: 801-434-5437
  • Fax:
Mailing address:
  • Phone: 801-434-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number8012319
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number370600-9921
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1174859060
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier1306080353
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name: DR. ADAM NICHOLAS SHEPHERD
Title or Position: PARTNER
Credential: DDS
Phone: 801-434-5437