Provider Demographics
NPI:1336548841
Name:OUT OF THIS WORLD DENTISTRY WJ PC
Entity Type:Organization
Organization Name:OUT OF THIS WORLD DENTISTRY WJ PC
Other - Org Name:OUT OF THIS WORLD DENTISTRY WJ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-898-7502
Mailing Address - Street 1:6787 S REDWOOD RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-2404
Mailing Address - Country:US
Mailing Address - Phone:801-542-7009
Mailing Address - Fax:801-748-0920
Practice Address - Street 1:6787 S REDWOOD RD
Practice Address - Street 2:SUITE #100
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-2404
Practice Address - Country:US
Practice Address - Phone:801-542-7009
Practice Address - Fax:801-748-0920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUT OF THIS WORLD DENTISTRY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1449371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty