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General NPI Number Information
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NPI Number | 1336548841
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Entity Type | Organization
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Legal Business Name | OUT OF THIS WORLD DENTISTRY WJ PC
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Dates
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Enumeration Date | 08/20/2014
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 6787 S REDWOOD RD SUITE #100
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City | WEST JORDAN
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State | UT
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Zip | 84084-2404
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Country | US
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Telephone | 801-542-7009
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Fax | 801-748-0920
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Provider Business Mailing Address
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Address Line | 6787 S REDWOOD RD SUITE #100
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City | WEST JORDAN
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State | UT
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Zip | 84084-2404
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Country | US
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Telephone | 801-542-7009
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Fax | 801-748-0920
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DANNIELLE STARK
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Credential |
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Telephone | 801-898-7502
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 144937
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License Number State | UT
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