Healthcare Provider Details

I. General information

NPI: 1679955017
Provider Name (Legal Business Name): SUMMIT ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 S STE 210
SALT LAKE CITY UT
84124-1348
US

IV. Provider business mailing address

1250 E 3900 S STE 210
SALT LAKE CITY UT
84124-1367
US

V. Phone/Fax

Practice location:
  • Phone: 801-265-1500
  • Fax: 801-265-9963
Mailing address:
  • Phone: 801-265-1500
  • Fax: 801-265-9963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7835316
License Number StateUT

VIII. Authorized Official

Name: BARBARA J DURANT
Title or Position: COLLECTION MANAGER
Credential:
Phone: 801-265-1500