Provider Demographics
NPI:1659009348
Name:WISDOM TEETH NOW LLC
Entity Type:Organization
Organization Name:WISDOM TEETH NOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-879-1048
Mailing Address - Street 1:PO BOX 900421
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-0421
Mailing Address - Country:US
Mailing Address - Phone:801-879-1048
Mailing Address - Fax:
Practice Address - Street 1:5801 S FASHION BLVD STE 195
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6159
Practice Address - Country:US
Practice Address - Phone:801-983-6802
Practice Address - Fax:801-983-6803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental