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General NPI Number Information
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NPI Number | 1518040591
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Entity Type | Organization
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Legal Business Name | ORAL MAXILLOFACIAL SURGERY, PLLC
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 05/13/2010
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Provider Practice Location Address
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Address Line | 912 N 2000 W
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City | PLEASANT GROVE
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State | UT
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Zip | 84062-4047
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Country | US
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Telephone | 801-756-0766
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Fax |
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Provider Business Mailing Address
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Address Line | 777 N 500 W SUITE 102
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City | PROVO
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State | UT
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Zip | 84601-1541
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Country | US
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Telephone | 801-375-4707
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Fax |
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Authorized Official
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Title or Position | ASST. OFFICE MANAGER
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Name | JANINE GALE
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Credential |
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Telephone | 801-375-4707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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