Provider Demographics
NPI:1740023779
Name:PLANET TOOTH LLC
Entity type:Organization
Organization Name:PLANET TOOTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-974-5437
Mailing Address - Street 1:2682 ANNA CAROLINE DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-5003
Mailing Address - Country:US
Mailing Address - Phone:801-974-5437
Mailing Address - Fax:801-964-9003
Practice Address - Street 1:2682 ANNA CAROLINE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-5003
Practice Address - Country:US
Practice Address - Phone:801-974-5437
Practice Address - Fax:801-964-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528554859000Medicaid