Healthcare Provider Details

I. General information

NPI: 1508877515
Provider Name (Legal Business Name): JERRY L SHAW DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 N 2000 W
FARR WEST UT
84404
US

IV. Provider business mailing address

1761 N 2000 W
FARR WEST UT
84404
US

V. Phone/Fax

Practice location:
  • Phone: 801-731-4850
  • Fax: 801-731-4852
Mailing address:
  • Phone: 801-731-4850
  • Fax: 801-731-4852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number132357
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number132357
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: