Provider Demographics
NPI:1912396060
Name:WEST JORDAN SMILE CENTER
Entity Type:Organization
Organization Name:WEST JORDAN SMILE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPP
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:801-318-4572
Mailing Address - Street 1:9251 S REDWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84008
Mailing Address - Country:US
Mailing Address - Phone:801-260-2847
Mailing Address - Fax:
Practice Address - Street 1:9251 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5814
Practice Address - Country:US
Practice Address - Phone:801-260-2847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMILE CENTER PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT142531122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty