Provider Demographics
NPI:1043627607
Name:HEBER VALLEY ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:HEBER VALLEY ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-315-2050
Mailing Address - Street 1:493 S MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-2240
Mailing Address - Country:US
Mailing Address - Phone:435-315-2050
Mailing Address - Fax:435-503-9526
Practice Address - Street 1:493 S MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2240
Practice Address - Country:US
Practice Address - Phone:435-315-2050
Practice Address - Fax:435-503-9526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty