Provider Demographics
NPI:1891394631
Name:VINEYARD ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:VINEYARD ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-766-4834
Mailing Address - Street 1:3300 N RUNNING CREEK WAY STE H210
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5871
Mailing Address - Country:US
Mailing Address - Phone:801-766-4834
Mailing Address - Fax:801-766-2315
Practice Address - Street 1:707 E MILL RD STE 102
Practice Address - Street 2:
Practice Address - City:VINEYARD
Practice Address - State:UT
Practice Address - Zip Code:84059-5732
Practice Address - Country:US
Practice Address - Phone:801-766-4834
Practice Address - Fax:801-766-2315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty