Provider Demographics
NPI:1700409695
Name:WASATCH DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WASATCH DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-254-7003
Mailing Address - Street 1:1685 W TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8697
Mailing Address - Country:US
Mailing Address - Phone:801-254-7003
Mailing Address - Fax:801-281-8455
Practice Address - Street 1:1685 W TOWNE CENTER DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8697
Practice Address - Country:US
Practice Address - Phone:801-254-7003
Practice Address - Fax:801-281-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1164883104OtherNPI