Healthcare Provider Details

I. General information

NPI: 1073856316
Provider Name (Legal Business Name): CHASE ROGER JUDD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11760 S 700 E STE 110
DRAPER UT
84020-6605
US

IV. Provider business mailing address

4150 CLEMENT ST #160
SAN FRANCISCO CA
94121-1545
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-6688
  • Fax:
Mailing address:
  • Phone: 415-750-2046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number10068298-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: