Provider Demographics
NPI:1629581871
Name:GENESIS DENTAL OF PROVO
Entity Type:Organization
Organization Name:GENESIS DENTAL OF PROVO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
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 1:2255 N UNIVERSITY PKWY STE 39
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1503
Mailing Address - Country:US
Mailing Address - Phone:801-319-6743
Mailing Address - Fax:
Practice Address - Street 1:2255 N UNIVERSITY PKWY STE 39
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1503
Practice Address - Country:US
Practice Address - Phone:801-319-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental