Provider Demographics
NPI:1558487827
Name:REDWOOD PERIODONTICS, LLC
Entity Type:Organization
Organization Name:REDWOOD PERIODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:MANWARING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:801-293-8833
Mailing Address - Street 1:6287 S REDWOOD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6653
Mailing Address - Country:US
Mailing Address - Phone:801-293-8833
Mailing Address - Fax:801-293-8844
Practice Address - Street 1:6287 S REDWOOD RD STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-6653
Practice Address - Country:US
Practice Address - Phone:801-293-8833
Practice Address - Fax:801-293-8844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT568279699221223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty