MEDICARE: GREGORY WILLIAM EGBERT DDS, MSD

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	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	143512	UT

General Provider Information

NPI Number	:	1700809969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY WILLIAM EGBERT DDS, MSD

Provider Business Mailing Address
First Line	:	1250 E 3900 SO
Second Line	:	STE 210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1367
Country	:	US
Telephone Number	:	801-265-1500
Fax Number	:	801-265-9963

Provider Business Practice Location Address
First Line	:	1250 E 3900 S
Second Line	:	STE 210
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1367
Country	:	US
Telephone Number	:	801-265-1500
Fax Number	:	801-265-9963

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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