Basic Information
| Provider Information | |||||||||
| NPI: | 1407261506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UTAH FACIAL & ORAL SURGERY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3473 W SOUTH JORDAN PKWY | ||||||||
| Address2: | #4 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840956015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014464428 | ||||||||
| FaxNumber: | 8015420071 | ||||||||
| Practice Location | |||||||||
| Address1: | 3473 W SOUTH JORDAN PKWY | ||||||||
| Address2: | #4 | ||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840956015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014464428 | ||||||||
| FaxNumber: | 8015420071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2014 | ||||||||
| LastUpdateDate: | 06/26/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8014464428 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 6922082-9924 | UT | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.