Organization
ORAL MAXILLOFACIAL SURGERY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JANINE GALE (ASST. OFFICE MANAGER)
(801) 375-4707
Entity
Organization
Contact information
Practice address
777 N 500 W, SUITE 102, PROVO, UT 84601-1541
(801) 375-4707
Mailing address
777 N 500 W, SUITE 102, PROVO, UT 84601-1541
(801) 375-4707
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
64166
PEHP
UT
Enumeration date
10/23/2006
Last updated
04/07/2015
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