Provider Demographics
NPI:1689333908
Name:WASATCH KIDS PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:WASATCH KIDS PEDIATRIC DENTISTRY, LLC
Other - Org Name:SALT LAKE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:EILEEN
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-414-1163
Mailing Address - Street 1:6151 SOUTH REDWOOD ROAD
Mailing Address - Street 2:STE. 200
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5332
Mailing Address - Country:US
Mailing Address - Phone:801-441-2144
Mailing Address - Fax:801-278-0481
Practice Address - Street 1:6151 SOUTH REDWOOD ROAD
Practice Address - Street 2:STE. 200
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5332
Practice Address - Country:US
Practice Address - Phone:801-441-2144
Practice Address - Fax:801-278-0481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty