Provider Demographics
NPI:1821428921
Name:WASATCH ENDODONTICS, PC
Entity Type:Organization
Organization Name:WASATCH ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-298-1101
Mailing Address - Street 1:185 S 400 E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4801
Mailing Address - Country:US
Mailing Address - Phone:801-298-1101
Mailing Address - Fax:801-298-1104
Practice Address - Street 1:185 S 400 E
Practice Address - Street 2:SUITE 201
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4801
Practice Address - Country:US
Practice Address - Phone:801-298-1101
Practice Address - Fax:801-298-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7270739-9922302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization