Provider Demographics
NPI:1437922465
Name:REDWOOD ORTHODONTICS
Entity Type:Organization
Organization Name:REDWOOD ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EBONIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-850-3769
Mailing Address - Street 1:6287 S REDWOOD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6655
Mailing Address - Country:US
Mailing Address - Phone:801-262-3777
Mailing Address - Fax:
Practice Address - Street 1:6287 S REDWOOD RD STE 202
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6655
Practice Address - Country:US
Practice Address - Phone:801-262-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty