Healthcare Provider Details

I. General information

NPI: 1528518909
Provider Name (Legal Business Name): WISDOM TEETH ONLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 N UNIVERSITY PKWY STE 8A
PROVO UT
84604-6702
US

IV. Provider business mailing address

2230 N UNIVERSITY PKWY STE 8A
PROVO UT
84604-6702
US

V. Phone/Fax

Practice location:
  • Phone: 801-370-0050
  • Fax: 801-370-9635
Mailing address:
  • Phone: 801-370-0050
  • Fax: 801-370-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number134055
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number187982
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number5594772
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5136597
License Number StateUT

VIII. Authorized Official

Name: MS. ELIZABETH GARCIA
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-370-0050