Healthcare Provider Details

I. General information

NPI: 1912507153
Provider Name (Legal Business Name): LEGACY HEIGHTS ORAL & FACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 S 200 W STE B
FARMINGTON UT
84025-2406
US

IV. Provider business mailing address

193 S 200 W STE B
FARMINGTON UT
84025-2406
US

V. Phone/Fax

Practice location:
  • Phone: 801-698-7121
  • Fax:
Mailing address:
  • Phone: 801-698-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAYNE ROBERT JENSEN
Title or Position: OWNER/ORAL SURGEON
Credential: MD, DMD
Phone: 801-698-7121