Healthcare Provider Details

I. General information

NPI: 1699916502
Provider Name (Legal Business Name): JAMSTAN P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 FORT UNION BLVD STE 102
MIDVALE UT
84047-5645
US

IV. Provider business mailing address

204 FORT UNION BLVD STE 102
MIDVALE UT
84047-5645
US

V. Phone/Fax

Practice location:
  • Phone: 801-561-9999
  • Fax: 801-561-9979
Mailing address:
  • Phone: 801-561-9999
  • Fax: 801-561-9979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number343288-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number343288-8903
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number366356-8903
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3663569921
License Number StateUT

VIII. Authorized Official

Name: LINDSEY R GODWIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 801-561-9999