MEDICARE: UTAH & ORAL & FACIAL SURGEONS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	64341369924	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063880896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UTAH & ORAL & FACIAL SURGEONS

Provider Business Mailing Address
First Line	:	6268 S 900 E
Second Line	:	100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:	801-566-5119

Provider Business Practice Location Address
First Line	:	6268 S 900 E
Second Line	:	100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-2497
Country	:	US
Telephone Number	:	801-566-5117
Fax Number	:	801-566-5119

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ALVIN JOHN STOSICH
Credential	:	DDS, MD
Telephone Number	:	801-566-5117

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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Directions to “UTAH & ORAL & FACIAL SURGEONS ” Practice Location

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