Provider Demographics
NPI:1821400532
Name:SOUTHWEST ORAL AND FACIAL SURGERY INC
Entity Type:Organization
Organization Name:SOUTHWEST ORAL AND FACIAL SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:801-938-3412
Mailing Address - Street 1:11748 S 3600 W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-5922
Mailing Address - Country:US
Mailing Address - Phone:801-938-3412
Mailing Address - Fax:801-938-3413
Practice Address - Street 1:11748 S 3600 W
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5922
Practice Address - Country:US
Practice Address - Phone:801-938-3412
Practice Address - Fax:801-938-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT355097-9924261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery