Healthcare Provider Details

I. General information

NPI: 1477270403
Provider Name (Legal Business Name): SPRINGVILLE ORAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 E 400 S
SPRINGVILLE UT
84663-1900
US

IV. Provider business mailing address

269 E 400 S
SPRINGVILLE UT
84663-1900
US

V. Phone/Fax

Practice location:
  • Phone: 801-704-5432
  • Fax: 801-704-5431
Mailing address:
  • Phone: 801-704-5432
  • Fax: 801-704-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY N PAVICK
Title or Position: SR. OPERATIONS MANAGER
Credential:
Phone: 801-857-7947