Provider Demographics
NPI:1578323143
Name:WISDOM TEETH EXPERTS
Entity Type:Organization
Organization Name:WISDOM TEETH EXPERTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:MCCUSKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-521-2757
Mailing Address - Street 1:285 W 530 N
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-4817
Mailing Address - Country:US
Mailing Address - Phone:949-521-2757
Mailing Address - Fax:
Practice Address - Street 1:9271 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6572
Practice Address - Country:US
Practice Address - Phone:949-521-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty