Healthcare Provider Details

I. General information

NPI: 1780198564
Provider Name (Legal Business Name): TOOTH DOCTOR - WVC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3060 S REDWOOD RD
WEST VALLEY CITY UT
84119-3058
US

IV. Provider business mailing address

3060 S REDWOOD RD
WEST VALLEY CITY UT
84119-3058
US

V. Phone/Fax

Practice location:
  • Phone: 801-972-0555
  • Fax:
Mailing address:
  • Phone: 801-972-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number88136909922
License Number StateUT

VIII. Authorized Official

Name: DR. DEVIN J ORVIN
Title or Position: PRESIDENT
Credential: DDS
Phone: 801-989-7803