Healthcare Provider Details

I. General information

NPI: 1093713554
Provider Name (Legal Business Name): DAVIS CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W HERITAGE PARK BLVD. SUITE 103
LAYTON UT
84041
US

IV. Provider business mailing address

890 W HERITAGE PARK BLVD. SUITE 103
LAYTON UT
84041
US

V. Phone/Fax

Practice location:
  • Phone: 801-614-0999
  • Fax: 801-614-0998
Mailing address:
  • Phone: 801-614-0999
  • Fax: 801-614-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4124
License Number StateUT

VIII. Authorized Official

Name: PAUL BENSON
Title or Position: OWNER
Credential: DMD
Phone: 801-614-0999