Provider Demographics
NPI:1992298533
Name:DR WISDOM TEETH
Entity type:Organization
Organization Name:DR WISDOM TEETH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:702-325-7627
Mailing Address - Street 1:287 E HUNT HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5096
Mailing Address - Country:US
Mailing Address - Phone:833-394-7366
Mailing Address - Fax:
Practice Address - Street 1:287 E HUNT HWY STE 101
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5096
Practice Address - Country:US
Practice Address - Phone:833-394-7366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009399261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental