Healthcare Provider Details

I. General information

NPI: 1205111432
Provider Name (Legal Business Name): JERRY L. SHAW, D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 N. 2000 W.
FARR WEST UT
84404-9541
US

IV. Provider business mailing address

1761 N. 2000 W.
FARR WEST UT
84404-9541
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 TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number132357
License Number StateUT

VIII. Authorized Official

Name: DR. JERRY L. SHAW
Title or Position: OWNER
Credential: DDS
Phone: 801-731-4850