Provider Demographics
NPI:1467916528
Name:WISDOM TEETH OF SOUTHERN UTAH
Entity Type:Organization
Organization Name:WISDOM TEETH OF SOUTHERN UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MD
Authorized Official - Phone:435-673-3490
Mailing Address - Street 1:446 S MALL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4944
Mailing Address - Country:US
Mailing Address - Phone:435-673-3490
Mailing Address - Fax:435-627-9954
Practice Address - Street 1:446 S MALL DR STE 100
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4944
Practice Address - Country:US
Practice Address - Phone:435-673-3490
Practice Address - Fax:435-627-9954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. GEORGE KIDS DENTAL AT SNOW CANYON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1881926509OtherNPI