Provider Demographics
NPI:1548775216
Name:HEALTHY IMAGE ORAL & MAXILLOFACIAL RADIOLOGY
Entity type:Organization
Organization Name:HEALTHY IMAGE ORAL & MAXILLOFACIAL RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:S
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:385-444-3210
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-0656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14056 S CHARDONNAY WAY
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-3857
Practice Address - Country:US
Practice Address - Phone:385-444-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Single Specialty