Provider Demographics
NPI:1558760959
Name:OUT OF THIS WORLD DENTISTRY PC
Entity Type:Organization
Organization Name:OUT OF THIS WORLD DENTISTRY PC
Other - Org Name:OUT OF THIS WORLD DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-898-7502
Mailing Address - Street 1:112 E 12450 S STE 100
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8057
Mailing Address - Country:US
Mailing Address - Phone:801-571-6751
Mailing Address - Fax:801-571-4156
Practice Address - Street 1:112 E 12450 S STE 100
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8057
Practice Address - Country:US
Practice Address - Phone:801-571-6751
Practice Address - Fax:801-571-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1449371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty