Provider Demographics
NPI:1467877910
Name:GENESIS DENTAL OF ST. GEORGE
Entity Type:Organization
Organization Name:GENESIS DENTAL OF ST. GEORGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:CASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-870-0625
Mailing Address - Street 1:6087 S REDWOOD RD STE C
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6854
Mailing Address - Country:US
Mailing Address - Phone:801-870-0625
Mailing Address - Fax:
Practice Address - Street 1:1449 N 1400 W
Practice Address - Street 2:SUITE A1
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5960
Practice Address - Country:US
Practice Address - Phone:435-656-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty