Provider Demographics
NPI:1578755948
Name:OSTERHOUDT, DARRELL (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:
Last Name:OSTERHOUDT
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:DR
Other - First Name:DARRELL
Other - Middle Name:
Other - Last Name:OSTERHOUDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD, MS
Mailing Address - Street 1:9217 S REDWOOD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5826
Mailing Address - Country:US
Mailing Address - Phone:801-568-0172
Mailing Address - Fax:801-568-3932
Practice Address - Street 1:9217 S REDWOOD RD
Practice Address - Street 2:SUITE C
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5826
Practice Address - Country:US
Practice Address - Phone:801-568-0172
Practice Address - Fax:801-568-3932
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTH061581223G0001X
UT5138167-99221223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice