Provider Demographics
NPI:1881174431
Name:FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.
Entity type:Organization
Organization Name:FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:MORONI
Authorized Official - Last Name:DAZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-916-0829
Mailing Address - Street 1:4117 N. 2600 E
Mailing Address - Street 2:
Mailing Address - City:FILER
Mailing Address - State:ID
Mailing Address - Zip Code:83328
Mailing Address - Country:US
Mailing Address - Phone:801-916-0829
Mailing Address - Fax:
Practice Address - Street 1:4401 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-3507
Practice Address - Country:US
Practice Address - Phone:307-352-8930
Practice Address - Fax:307-352-8947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL4296207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty