Healthcare Provider Details

I. General information

NPI: 1831941095
Provider Name (Legal Business Name): ORAGEN IN-HOUSE SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11996 S ANTHEM PARK BLVD # 100
HERRIMAN UT
84096-5643
US

IV. Provider business mailing address

PO BOX 285
CENTERVILLE UT
84014-0285
US

V. Phone/Fax

Practice location:
  • Phone: 801-448-0366
  • Fax:
Mailing address:
  • Phone: 801-448-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY PAVICK
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 802-857-7947