Healthcare Provider Details

I. General information

NPI: 1760745251
Provider Name (Legal Business Name): INTERMOUNTAIN ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6287 S REDWOOD RD #103
TAYLORSVILLE UT
84123-6634
US

IV. Provider business mailing address

6287 S REDWOOD RD #103
TAYLORSVILLE UT
84123-6634
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-2444
  • Fax:
Mailing address:
  • Phone: 801-261-2444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberLIC-4-12-7785
License Number StateUT

VIII. Authorized Official

Name: DR. MARK RYSER
Title or Position: ORAL SURGEON
Credential: DMD
Phone: 801-261-2444