Healthcare Provider Details

I. General information

NPI: 1962918094
Provider Name (Legal Business Name): SOUTHERN UTAH SURGICAL ARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 12/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 E RIVERSIDE DR, STE 2B
ST. GEORGE UT
84790
US

IV. Provider business mailing address

393 E RIVERSIDE DR, STE 2B
ST GEORGE UT
84790
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-1100
  • Fax: 435-673-0330
Mailing address:
  • Phone: 435-628-1100
  • Fax: 435-673-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD07932
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6524667
License Number StateUT

VIII. Authorized Official

Name: DR. SHAWN B DAVIS
Title or Position: OWNER
Credential: DMD
Phone: 435-628-1100