Provider Demographics
NPI:1962918094
Name:SOUTHERN UTAH SURGICAL ARTS
Entity type:Organization
Organization Name:SOUTHERN UTAH SURGICAL ARTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-628-1100
Mailing Address - Street 1:393 E RIVERSIDE DR, STE 2B
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:435-628-1100
Mailing Address - Fax:435-673-0330
Practice Address - Street 1:393 E RIVERSIDE DR, STE 2B
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-628-1100
Practice Address - Fax:435-673-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-27
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6524667204E00000X
AZD07932204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty