Healthcare Provider Details

I. General information

NPI: 1689795114
Provider Name (Legal Business Name): ALVIN J STOSICH MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

6268 S 900 E STE 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 TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6434136-9925
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6395
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6434136-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: