Healthcare Provider Details

I. General information

NPI: 1558744748
Provider Name (Legal Business Name): RYAN K AUSTIN, DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5742 S 1475 E STE 100
SOUTH OGDEN UT
84403-4857
US

IV. Provider business mailing address

5742 S 1475 E STE 100
SOUTH OGDEN UT
84403-4857
US

V. Phone/Fax

Practice location:
  • Phone: 801-399-3701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number9105773
License Number StateUT

VIII. Authorized Official

Name: RYAN AUSTIN
Title or Position: OWNER
Credential:
Phone: 801-399-3701