1255857728 NPI number — SIMPLY WISDOM TEETH PLLC

Table of content: (NPI 1255857728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255857728 NPI number — SIMPLY WISDOM TEETH PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIMPLY WISDOM TEETH PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255857728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
352 E RIVERSIDE DR STE A9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT GEORGE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84790-5812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-652-1243
Provider Business Mailing Address Fax Number:
435-652-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
352 E RIVERSIDE DR STE A9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT GEORGE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84790-5812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-652-1243
Provider Business Practice Location Address Fax Number:
435-652-1243
Provider Enumeration Date:
08/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKSON
Authorized Official First Name:
NIELS
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
435-215-6621

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  143297 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 528948205 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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