Provider Demographics
NPI:1427452614
Name:GENESIS DENTAL OF SOUTH JORDAN
Entity type:Organization
Organization Name:GENESIS DENTAL OF SOUTH JORDAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CASTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-870-0625
Mailing Address - Street 1:12180 S 300 E UNIT 270
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-2612
Mailing Address - Country:US
Mailing Address - Phone:801-870-0625
Mailing Address - Fax:
Practice Address - Street 1:11531 S DISTRICT DR STE 600
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5782
Practice Address - Country:US
Practice Address - Phone:801-254-7272
Practice Address - Fax:801-254-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty