Healthcare Provider Details

I. General information

NPI: 1629205034
Provider Name (Legal Business Name): RYAN K AUSTIN D.D.S., P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 10/17/2016
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: 801-399-3701
  • Fax: 801-399-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9657
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9105773
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: