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General NPI Number Information
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NPI Number | 1255857728
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Entity Type | Organization
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Legal Business Name | SIMPLY WISDOM TEETH PLLC
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Dates
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Enumeration Date | 08/16/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 352 E RIVERSIDE DR STE A9
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City | SAINT GEORGE
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State | UT
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Zip | 84790-5812
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Country | US
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Telephone | 435-652-1243
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Fax | 435-652-1243
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Provider Business Mailing Address
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Address Line | 352 E RIVERSIDE DR STE A9
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City | SAINT GEORGE
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State | UT
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Zip | 84790-5812
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Country | US
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Telephone | 435-652-1243
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Fax | 435-652-1243
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Authorized Official
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Title or Position | MANAGER
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Name | MR. NIELS HENDRICKSON
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Credential |
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Telephone | 435-215-6621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 143297
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License Number State | UT
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