Provider Demographics
NPI:1609372903
Name:GENESIS ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:GENESIS ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:CASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-870-0625
Mailing Address - Street 1:12180 S 300 E UNIT 270
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-2612
Mailing Address - Country:US
Mailing Address - Phone:801-969-9070
Mailing Address - Fax:
Practice Address - Street 1:3725 W 4100 S STE 240
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5530
Practice Address - Country:US
Practice Address - Phone:801-969-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-04
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144139261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental