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General NPI Number Information
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NPI Number | 1881174431
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Entity Type | Organization
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Legal Business Name | FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 4401 COLLEGE DR
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City | ROCK SPRINGS
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State | WY
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Zip | 82901-3507
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Country | US
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Telephone | 307-352-8930
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Fax | 307-352-8947
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Provider Business Mailing Address
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Address Line | 4117 N. 2600 E
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City | FILER
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State | ID
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Zip | 83328
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Country | US
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Telephone | 801-916-0829
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Fax |
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Authorized Official
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Title or Position | ORGANIZER
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Name | MR. JUSTIN MORONI DAZLEY
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Credential | M.D.
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Telephone | 801-916-0829
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | TL4296
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 207XS0117X
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Taxonomy Name | Orthopaedic Surgery of the Spine Physician
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License Number | TL4296
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License Number State | WY
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