Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 4761040-9922 | UT |
NPI | 1033329669 |
---|---|
Provider Name | Dr. Timothy B. Elison |
First Address | South Jordan, UT 84095-3211 |
Second Address | South Jordan, UT 84095-3211 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 08/07/2007 |