Provider Demographics
NPI:1245601012
Name:ORAL & MAXILLOFACIAL SURGEONS OF UTAH
Entity Type:Organization
Organization Name:ORAL & MAXILLOFACIAL SURGEONS OF UTAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:LISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:801-779-0506
Mailing Address - Street 1:2297 N. HILL FIELD ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-779-0506
Mailing Address - Fax:
Practice Address - Street 1:2297 N HILL FIELD RD
Practice Address - Street 2:SUITE 105
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6920
Practice Address - Country:US
Practice Address - Phone:801-779-0506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty