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General NPI Number Information
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NPI Number | 1730224643
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Entity Type | Organization
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Legal Business Name | KIDZ DENTAL WORKS
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Dates
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Enumeration Date | 02/20/2007
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Last Update Date | 07/14/2008
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Provider Practice Location Address
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Address Line | 780 S 2000 W BLDG F2
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City | SYRACUSE
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State | UT
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Zip | 84075
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Country | US
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Telephone | 801-776-8176
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Fax | 801-774-9085
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Provider Business Mailing Address
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Address Line | 780 S 2000 W BLDG F2
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City | SYRACUSE
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State | UT
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Zip | 84075
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Country | US
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Telephone | 801-776-8176
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Fax | 801-774-9085
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Authorized Official
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Title or Position | OWNER
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Name | DR. GARY SCOTT WALL
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Credential | DDS
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Telephone | 801-776-8176
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 266402
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License Number State | UT
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