Provider Demographics
NPI:1992403661
Name:LEGACY HEIGHTS SURGERY CENTER PC
Entity type:Organization
Organization Name:LEGACY HEIGHTS SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:DAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-335-6086
Mailing Address - Street 1:1379 N 1075 W STE 100B
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2711
Mailing Address - Country:US
Mailing Address - Phone:801-335-6086
Mailing Address - Fax:801-335-6087
Practice Address - Street 1:1379 N 1075 W STE 100B
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2711
Practice Address - Country:US
Practice Address - Phone:801-335-6086
Practice Address - Fax:801-335-6087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty