Healthcare Provider Details

I. General information

NPI: 1821400532
Provider Name (Legal Business Name): SOUTHWEST ORAL AND FACIAL SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11748 S 3600 W SUITE 1
SOUTH JORDAN UT
84095-5922
US

IV. Provider business mailing address

11748 S 3600 W SUITE 1
SOUTH JORDAN UT
84095-5922
US

V. Phone/Fax

Practice location:
  • Phone: 801-938-3412
  • Fax: 801-938-3413
Mailing address:
  • Phone: 801-938-3412
  • Fax: 801-938-3413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number355097-9924
License Number StateUT

VIII. Authorized Official

Name: MR. JARED MATHEW BROWN
Title or Position: OWNER/SURGEON
Credential: D.D.S, M.D
Phone: 801-938-3412