Provider Demographics
NPI:1275899809
Name:UTAH ORAL SURGERY & DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:UTAH ORAL SURGERY & DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-269-1110
Mailing Address - Street 1:6243 S REDWOOD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6243 S REDWOOD RD STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-6408
Practice Address - Country:US
Practice Address - Phone:801-269-1110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6216924-9924204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty