Healthcare Provider Details

I. General information

NPI: 1972683498
Provider Name (Legal Business Name): DEAN DENNIS SEVERSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 N MAIN ST
TOOELE UT
84074-9819
US

IV. Provider business mailing address

PO BOX 210
ROY UT
84067-0210
US

V. Phone/Fax

Practice location:
  • Phone: 435-843-3600
  • Fax:
Mailing address:
  • Phone: 81-825-4700
  • Fax: 801-825-9076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6280859-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: