Provider Demographics
NPI:1689795114
Name:STOSICH, ALVIN J (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:ALVIN
Middle Name:J
Last Name:STOSICH
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6268 S 900 E
Mailing Address - Street 2:STE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2497
Mailing Address - Country:US
Mailing Address - Phone:801-566-5117
Mailing Address - Fax:801-566-5119
Practice Address - Street 1:6268 S 900 E
Practice Address - Street 2:STE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2497
Practice Address - Country:US
Practice Address - Phone:801-566-5117
Practice Address - Fax:801-566-5119
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6434136-99251223S0112X
NE6395204E00000X
UT6434136-1205204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery