Healthcare Provider Details

I. General information

NPI: 1952244642
Provider Name (Legal Business Name): BRIGHTSIDE ORAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5136 N CAMBRIDGE WAY
STANSBURY PARK UT
84074-8279
US

IV. Provider business mailing address

5136 N CAMBRIDGE WAY
STANSBURY PARK UT
84074-8279
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax: 801-773-9828
Mailing address:
  • Phone: 801-773-8644
  • Fax: 801-773-9828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: EBONIE GONZALES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 505-850-3769