Provider Demographics
NPI:1992119622
Name:WENDOVER DENTAL CARE PC
Entity type:Organization
Organization Name:WENDOVER DENTAL CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:D
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-665-2962
Mailing Address - Street 1:PO BOX 625
Mailing Address - Street 2:
Mailing Address - City:WENDOVER
Mailing Address - State:UT
Mailing Address - Zip Code:84083-0625
Mailing Address - Country:US
Mailing Address - Phone:435-665-2962
Mailing Address - Fax:435-665-7525
Practice Address - Street 1:399 N ARIA BLVD
Practice Address - Street 2:
Practice Address - City:WENDOVER
Practice Address - State:UT
Practice Address - Zip Code:84083-0625
Practice Address - Country:US
Practice Address - Phone:435-665-2962
Practice Address - Fax:435-665-7525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3249281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1205884657Medicaid