Healthcare Provider Details

I. General information

NPI: 1841169224
Provider Name (Legal Business Name): WASATCH PEDIATRICS - SOUTHPOINT DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9071 S 1300 W STE 100
WEST JORDAN UT
84088-6673
US

IV. Provider business mailing address

9071 S 1300 W STE 205
WEST JORDAN UT
84088-6725
US

V. Phone/Fax

Practice location:
  • Phone: 801-453-9625
  • Fax: 801-944-7347
Mailing address:
  • Phone: 801-453-9625
  • Fax: 801-944-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALYSHIA RICE
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 801-453-9625