Provider Demographics
NPI:1992930861
Name:WILLDEN FAMILY DENTAL INC.
Entity type:Organization
Organization Name:WILLDEN FAMILY DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:HYMAS
Authorized Official - Last Name:WILLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-446-4668
Mailing Address - Street 1:3632 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-7162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3632 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 202
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-7162
Practice Address - Country:US
Practice Address - Phone:801-446-4668
Practice Address - Fax:801-446-6037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT532623499221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty