Provider Demographics
NPI:1568866119
Name:EASY WISDOM TEETH LLC
Entity Type:Organization
Organization Name:EASY WISDOM TEETH LLC
Other - Org Name:EASY WISDOM TEETH
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MARZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-886-3379
Mailing Address - Street 1:2222 W 3500 S
Mailing Address - Street 2:A1
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3464
Mailing Address - Country:US
Mailing Address - Phone:801-886-3379
Mailing Address - Fax:
Practice Address - Street 1:2222 W 3500 S
Practice Address - Street 2:A1
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3464
Practice Address - Country:US
Practice Address - Phone:801-886-3379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT275551-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty