Provider Demographics
NPI:1679955017
Name:SUMMIT ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:SUMMIT ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COLLECTION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DURANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-265-1500
Mailing Address - Street 1:1250 E 3900 S STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1367
Mailing Address - Country:US
Mailing Address - Phone:801-265-1500
Mailing Address - Fax:801-265-9963
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:STE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-265-1500
Practice Address - Fax:801-265-9963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-22
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT78353161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty