Provider Demographics
NPI:1356084107
Name:ST. GEORGE RED ROCKS PC
Entity Type:Organization
Organization Name:ST. GEORGE RED ROCKS PC
Other - Org Name:ST. GEORGE RED ROCKS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ORAL SURGEON/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-997-9017
Mailing Address - Street 1:624 S 1000 E STE 107
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5902
Mailing Address - Country:US
Mailing Address - Phone:435-289-6600
Mailing Address - Fax:435-289-6900
Practice Address - Street 1:624 S 1000 E STE 107
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5902
Practice Address - Country:US
Practice Address - Phone:435-289-6600
Practice Address - Fax:435-289-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty