Provider Demographics
NPI:1063880896
Name:UTAH & ORAL & FACIAL SURGEONS
Entity type:Organization
Organization Name:UTAH & ORAL & FACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:STOSICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:801-566-5117
Mailing Address - Street 1:6268 S 900 E
Mailing Address - Street 2:100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-2497
Mailing Address - Country:US
Mailing Address - Phone:801-566-5117
Mailing Address - Fax:801-566-5119
Practice Address - Street 1:6268 S 900 E
Practice Address - Street 2:100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-2497
Practice Address - Country:US
Practice Address - Phone:801-566-5117
Practice Address - Fax:801-566-5119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT643413699241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT519239432001Medicaid
WY127067200Medicaid