MEDICARE: DR. JEFFREY AVARON OSGUTHORPE DDS, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	2901018951	MI
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4947070-9924	UT
3	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	2901018951	MI

General Provider Information

NPI Number	:	1427127422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY AVARON OSGUTHORPE DDS, MD

Provider Business Mailing Address
First Line	:	4645 S 4000 W STE B
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84120-6250
Country	:	US
Telephone Number	:	801-550-5103
Fax Number	:

Provider Business Practice Location Address
First Line	:	4645 S 4000 W STE B
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84120-6250
Country	:	US
Telephone Number	:	801-550-5103
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	04/15/2019

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