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General NPI Number Information
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NPI Number | 1811396260
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Entity Type | Organization
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Legal Business Name | OUT OF THIS WORLD DENTISTRY SJ PC
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Dates
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Enumeration Date | 08/21/2014
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 10426 S. 4000 W.
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City | SOUTH JORDAN
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State | UT
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Zip | 84009
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Country | US
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Telephone | 801-260-0400
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Fax | 801-619-5399
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Provider Business Mailing Address
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Address Line | 10426 S. 4000 W.
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City | SOUTH JORDAN
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State | UT
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Zip | 84009
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Country | US
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Telephone | 801-260-0400
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Fax | 801-619-5399
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Authorized Official
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Title or Position | OWNER
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Name | CORY STARK
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Credential | DDS
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Telephone | 801-260-0400
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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 |
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License Number State |
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