Provider Demographics
NPI:1205098324
Name:TODD C. LISTON DDS, MS, PC
Entity type:Organization
Organization Name:TODD C. LISTON DDS, MS, PC
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 HILL FIELD RD
Mailing Address - Street 2:BUILDING A, SUITE 105
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-6920
Mailing Address - Country:US
Mailing Address - Phone:801-779-0506
Mailing Address - Fax:801-779-4344
Practice Address - Street 1:469 MEDICAL DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4900
Practice Address - Country:US
Practice Address - Phone:801-299-8531
Practice Address - Fax:801-299-9667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2606051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000010946Medicare PIN