Provider Demographics
NPI:1255857728
Name:SIMPLY WISDOM TEETH PLLC
Entity type:Organization
Organization Name:SIMPLY WISDOM TEETH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:NIELS
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-215-6621
Mailing Address - Street 1:352 E RIVERSIDE DR STE A9
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5812
Mailing Address - Country:US
Mailing Address - Phone:435-652-1243
Mailing Address - Fax:435-652-1243
Practice Address - Street 1:352 E RIVERSIDE DR STE A9
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5812
Practice Address - Country:US
Practice Address - Phone:435-652-1243
Practice Address - Fax:435-652-1243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143297261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528948205Medicaid