Healthcare Provider Details

I. General information

NPI: 1184980005
Provider Name (Legal Business Name): ORAL & FACIAL RECONSTRUCTIVE SURGEONS OF UTAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E 3900 S STE 360
SALT LAKE CITY UT
84124-1362
US

IV. Provider business mailing address

1250 E 3900 S STE 360
SALT LAKE CITY UT
84124-1362
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-7447
  • Fax:
Mailing address:
  • Phone: 801-262-7447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7961990-1205
License Number StateUT

VIII. Authorized Official

Name: DR. NATHAN GRANT ADAMS
Title or Position: CO-OWNER, SURGEON
Credential: MD, DMD
Phone: 801-262-7447