Healthcare Provider Details

I. General information

NPI: 1366826224
Provider Name (Legal Business Name): SHAUN THOMAS HEWARD DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
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: 801-479-9070
  • Fax:
Mailing address:
  • Phone: 801-479-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901021498
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12210727-9925
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: