Provider Demographics
NPI:1780821124
Name:ORAL AND MAXILLOFACIAL SURGEONS OF UTAH, LLC
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGEONS OF UTAH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:C
Authorized Official - Last Name:LISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:801-779-0506
Mailing Address - Street 1:2297 N HILLFIELD RD
Mailing Address - Street 2:BUILDING A, SUITE 105
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6928
Mailing Address - Country:US
Mailing Address - Phone:801-779-0506
Mailing Address - Fax:801-779-4344
Practice Address - Street 1:2297 N HILLFIELD RD
Practice Address - Street 2:BUILDING A, SUITE 105
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-6928
Practice Address - Country:US
Practice Address - Phone:801-779-0506
Practice Address - Fax:801-779-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty