Healthcare Provider Details

I. General information

NPI: 1548349251
Provider Name (Legal Business Name): GREGORY SHANE JESSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 E SKYLINE DR STE 800
OGDEN UT
84405-4889
US

IV. Provider business mailing address

1508 E SKYLINE DR STE 800
OGDEN UT
84405-4889
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-8200
  • Fax: 801-479-3219
Mailing address:
  • Phone: 801-479-8200
  • Fax: 801-479-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number5219929-9924
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number52199299924
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5219929-9924
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: