Healthcare Provider Details

I. General information

NPI: 1811057995
Provider Name (Legal Business Name): ORTHODONTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 W 9800 S SUITE 103
SOUTH JORDAN UT
84095
US

IV. Provider business mailing address

3556 W 9800 S SUITE 103
SOUTH JORDAN UT
84095
US

V. Phone/Fax

Practice location:
  • Phone: 801-446-3549
  • Fax: 801-254-3656
Mailing address:
  • Phone: 801-446-3549
  • Fax: 801-254-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY B ELISON
Title or Position: PRESIDENT
Credential: DMD
Phone: 801-446-3549