Healthcare Provider Details

I. General information

NPI: 1063880896
Provider Name (Legal Business Name): UTAH & ORAL & FACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 S 900 E 100
SALT LAKE CITY UT
84121-2497
US

IV. Provider business mailing address

6268 S 900 E 100
SALT LAKE CITY UT
84121-2497
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-5117
  • Fax: 801-566-5119
Mailing address:
  • Phone: 801-566-5117
  • Fax: 801-566-5119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number64341369924
License Number StateUT

VIII. Authorized Official

Name: DR. ALVIN JOHN STOSICH
Title or Position: OWNER
Credential: DDS, MD
Phone: 801-566-5117