Healthcare Provider Details

I. General information

NPI: 1619710084
Provider Name (Legal Business Name): JAYSON MARK COLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2954 CARRINGTON RD FORT BLISS
APO AA
79916
US

IV. Provider business mailing address

638 E 25 S
EPHRAIM UT
84627-1278
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-3303
  • Fax:
Mailing address:
  • Phone: 435-851-9735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14006231-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: