Healthcare Provider Details

I. General information

NPI: 1124477294
Provider Name (Legal Business Name): JASON WAREHAM D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 S FASHION BLVD STE 100
MURRAY UT
84107
US

IV. Provider business mailing address

10894 S RIVER FRONT PKWY
SOUTH JORDAN UT
84095-5609
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-6661
  • Fax: 801-268-4820
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9844486-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: