Healthcare Provider Details

I. General information

NPI: 1457759425
Provider Name (Legal Business Name): HULSE DENTISRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N STATE ROAD 198
SALEM UT
84653-4504
US

IV. Provider business mailing address

601 N STATE ROAD 198
SALEM UT
84653-4504
US

V. Phone/Fax

Practice location:
  • Phone: 801-423-7969
  • Fax: 801-504-6158
Mailing address:
  • Phone: 801-423-7969
  • Fax: 801-504-6158

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: DAVID WENNERHOLM
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-423-7969