Provider Demographics
NPI:1821159567
Name:WOODMANSEE, TERRELL
Entity Type:Individual
Prefix:
First Name:TERRELL
Middle Name:
Last Name:WOODMANSEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5974 FASHION POINT DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4699
Mailing Address - Country:US
Mailing Address - Phone:801-475-6121
Mailing Address - Fax:
Practice Address - Street 1:5974 FASHION POINT DR
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4699
Practice Address - Country:US
Practice Address - Phone:801-475-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT309191-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice