Provider Demographics
NPI:1942757570
Name:YOUNG FAMILY DENTAL WJ
Entity type:Organization
Organization Name:YOUNG FAMILY DENTAL WJ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-224-0222
Mailing Address - Street 1:4800 W. 8159 S.
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8213
Mailing Address - Country:US
Mailing Address - Phone:801-601-8200
Mailing Address - Fax:801-996-3641
Practice Address - Street 1:4800 W. 8159 S.
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8213
Practice Address - Country:US
Practice Address - Phone:801-601-8200
Practice Address - Fax:801-996-3641
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YOUNG FAMILY DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47669431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4766943Medicaid