Provider Demographics
NPI:1487216685
Name:WASATCH PEDIATRIC DENTISTRY, PC
Entity Type:Organization
Organization Name:WASATCH PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:VEST
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-999-0234
Mailing Address - Street 1:1765 E 2450 N
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-4705
Mailing Address - Country:US
Mailing Address - Phone:801-360-8775
Mailing Address - Fax:435-514-1743
Practice Address - Street 1:530 W 465 N STE 703
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-8006
Practice Address - Country:US
Practice Address - Phone:435-999-0234
Practice Address - Fax:435-363-9151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1457794315Medicaid