Healthcare Provider Details

I. General information

NPI: 1114164365
Provider Name (Legal Business Name): SOUTHERN UTAH SURGICAL AND LASER AESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2009
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 E RIVERSIDE DR
ST GEORGE UT
84790-4477
US

IV. Provider business mailing address

1068 E RIVERSIDE DR
ST GEORGE UT
84790-4477
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-6466
  • Fax: 435-628-3845
Mailing address:
  • Phone: 435-628-6466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN CARTER
Title or Position: OWNER
Credential: M.D.
Phone: 435-628-6466