Healthcare Provider Details

I. General information

NPI: 1396769097
Provider Name (Legal Business Name): JOHN M POBANZ DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 E SKYLINE DR SUITE 200
OGDEN UT
84405-4846
US

IV. Provider business mailing address

1508 E SKYLINE DR SUITE 200
OGDEN UT
84405-4846
US

V. Phone/Fax

Practice location:
  • Phone: 801-627-0500
  • Fax: 801-394-8235
Mailing address:
  • Phone: 801-627-0500
  • Fax: 801-394-8235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number324289-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: