Provider Demographics
NPI:1730224643
Name:KIDZ DENTAL WORKS
Entity type:Organization
Organization Name:KIDZ DENTAL WORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-776-8176
Mailing Address - Street 1:780 S 2000 W
Mailing Address - Street 2:BLDG F2
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075
Mailing Address - Country:US
Mailing Address - Phone:801-776-8176
Mailing Address - Fax:801-774-9085
Practice Address - Street 1:780 S 2000 W
Practice Address - Street 2:BLDG F2
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075
Practice Address - Country:US
Practice Address - Phone:801-776-8176
Practice Address - Fax:801-774-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT266402122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528902470008Medicaid