Provider Demographics
NPI:1528385085
Name:STANSBURY PARK ORTHODONTICS
Entity Type:Organization
Organization Name:STANSBURY PARK ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-579-3800
Mailing Address - Street 1:263 COUNTRY CLUB
Mailing Address - Street 2:STE. 104
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-579-3800
Mailing Address - Fax:435-579-3590
Practice Address - Street 1:263 COUNTRY CLUB
Practice Address - Street 2:STE. 104
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-579-3800
Practice Address - Fax:435-579-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty