Provider Demographics
NPI:1760745251
Name:INTERMOUNTAIN ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:INTERMOUNTAIN ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RYSER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-261-2444
Mailing Address - Street 1:6287 S REDWOOD RD
Mailing Address - Street 2:#103
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6634
Mailing Address - Country:US
Mailing Address - Phone:801-261-2444
Mailing Address - Fax:
Practice Address - Street 1:6287 S REDWOOD RD
Practice Address - Street 2:#103
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-6634
Practice Address - Country:US
Practice Address - Phone:801-261-2444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTLIC-4-12-77851223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty