Provider Demographics
NPI:1568080497
Name:SAN ANTONIO WISDOM TEETH, PLLC
Entity Type:Organization
Organization Name:SAN ANTONIO WISDOM TEETH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-899-5512
Mailing Address - Street 1:5406 W 11000 N # 226
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13535 HAUSMAN PASS #102-A
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78249
Practice Address - Country:US
Practice Address - Phone:214-307-4039
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty