Healthcare Provider Details

I. General information

NPI: 1316442841
Provider Name (Legal Business Name): SJ ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3632 W SOUTH JORDAN PKWY STE 103
SOUTH JORDAN UT
84009-7163
US

IV. Provider business mailing address

3632 W SOUTH JORDAN PKWY STE 103
SOUTH JORDAN UT
84009-7163
US

V. Phone/Fax

Practice location:
  • Phone: 580-355-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number183
License Number StateOK

VIII. Authorized Official

Name: DAYNE JENSEN
Title or Position: PRESIDENT
Credential: MD, DMD
Phone: 801-698-7121