Provider Demographics
NPI:1629519723
Name:WASATCH PAYROLL LLC
Entity Type:Organization
Organization Name:WASATCH PAYROLL LLC
Other - Org Name:FOUR SEASONS DENTAL CARE N
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-375-1358
Mailing Address - Street 1:3100 N ACADEMY BLVD
Mailing Address - Street 2:107
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-5321
Mailing Address - Country:US
Mailing Address - Phone:719-375-1358
Mailing Address - Fax:
Practice Address - Street 1:3100 N ACADEMY BLVD
Practice Address - Street 2:107
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-5321
Practice Address - Country:US
Practice Address - Phone:719-375-1358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WASATCH PAYROLL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00202298261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental