Healthcare Provider Details

I. General information

NPI: 1821553785
Provider Name (Legal Business Name): RAYMOND SCOTT HLAVATY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 E 200 N STE A
LOGAN UT
84321-4036
US

IV. Provider business mailing address

150 E 200 N STE A
LOGAN UT
84321-4036
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-2828
  • Fax: 435-753-3628
Mailing address:
  • Phone: 435-753-2828
  • Fax: 435-753-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number260457
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: