Healthcare Provider Details

I. General information

NPI: 1346884335
Provider Name (Legal Business Name): ORTHODONTICS OF ST. GEORGE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 E 700 S STE 101
ST GEORGE UT
84790-4084
US

IV. Provider business mailing address

4760 N BUTLER AVE STE B
FARMINGTON NM
87401-0816
US

V. Phone/Fax

Practice location:
  • Phone: 435-688-7711
  • Fax:
Mailing address:
  • Phone: 505-592-0482
  • Fax: 505-325-2538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MISTY M ABEYTA
Title or Position: BILLING
Credential:
Phone: 505-592-0482