Provider Demographics
NPI:1629188172
Name:GENESIS DENTAL OF TOOELE, LLC
Entity Type:Organization
Organization Name:GENESIS DENTAL OF TOOELE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
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:801-838-8030
Mailing Address - Street 1:6087 S REDWOOD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5330
Mailing Address - Country:US
Mailing Address - Phone:801-838-8030
Mailing Address - Fax:801-352-1872
Practice Address - Street 1:1204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-9540
Practice Address - Country:US
Practice Address - Phone:435-882-8600
Practice Address - Fax:435-882-8605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty