MEDICARE: JERI LYNN BULLOCK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401414490	VA
2	1223G0001X	General Practice Dentistry	016.0078267	VT
3	1223G0001X	General Practice Dentistry	90-0809888	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396030003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERI LYNN BULLOCK DDS

Provider Business Mailing Address
First Line	:	1144 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-1804
Country	:	US
Telephone Number	:	801-566-3118
Fax Number	:

Provider Business Practice Location Address
First Line	:	1144 E FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-1804
Country	:	US
Telephone Number	:	801-566-3118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2011
Last Update Date	:	07/21/2022

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