Healthcare Provider Details

I. General information

NPI: 1427127422
Provider Name (Legal Business Name): JEFFREY AVARON OSGUTHORPE DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 S 4000 W STE B
WEST VALLEY UT
84120-6250
US

IV. Provider business mailing address

4645 S 4000 W STE B
WEST VALLEY UT
84120-6250
US

V. Phone/Fax

Practice location:
  • Phone: 801-550-5103
  • Fax:
Mailing address:
  • Phone: 801-550-5103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number4947070-9924
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901018951
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number2901018951
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: