Healthcare Provider Details

I. General information

NPI: 1174371546
Provider Name (Legal Business Name): JESSICA BIRRELL CDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 02/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11978 S 700 E STE 101
DRAPER UT
84020-9818
US

IV. Provider business mailing address

11978 S 700 E STE 101
DRAPER UT
84020-9818
US

V. Phone/Fax

Practice location:
  • Phone: 801-352-7002
  • Fax: 801-769-1246
Mailing address:
  • Phone: 801-352-7002
  • Fax: 801-769-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number223233500
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code126900000X
TaxonomyDental Laboratory Technician
License Number223233500
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: