MEDICARE: JUSTIN JAY NYBO DDS

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	1223G0001X	General Practice Dentistry	10387202-9922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10387202-9922	OTHER	UT	STATE LICENSE

General Provider Information

NPI Number	:	1841729027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN JAY NYBO DDS

Provider Business Mailing Address
First Line	:	525 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-3339
Country	:	US
Telephone Number	:	801-444-9911
Fax Number	:	801-544-2255

Provider Business Practice Location Address
First Line	:	525 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-3339
Country	:	US
Telephone Number	:	801-444-9911
Fax Number	:	801-544-2255

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

Provider Enumeration Date	:	06/09/2017
Last Update Date	:	03/07/2023

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