Provider Demographics
NPI:1528518909
Name:WISDOM TEETH ONLY
Entity type:Organization
Organization Name:WISDOM TEETH ONLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-370-0050
Mailing Address - Street 1:2230 N UNIVERSITY PKWY STE 8A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6702
Mailing Address - Country:US
Mailing Address - Phone:801-370-0050
Mailing Address - Fax:801-370-9635
Practice Address - Street 1:2230 N UNIVERSITY PKWY STE 8A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6702
Practice Address - Country:US
Practice Address - Phone:801-370-0050
Practice Address - Fax:801-370-9635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT134055122300000X
UT187982364S00000X
UT5594772364S00000X
UT5136597122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty