Healthcare Provider Details

I. General information

NPI: 1184991895
Provider Name (Legal Business Name): JESSEN OMFS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 E SKYLINE DR SUITE 800
OGDEN UT
84405-4846
US

IV. Provider business mailing address

1508 E SKYLINE DR SUITE 800
OGDEN UT
84405-4846
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 TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52199299924
License Number StateUT

VIII. Authorized Official

Name: DR. GREGORY SHANE JESSEN
Title or Position: OWNER
Credential: DDS
Phone: 801-479-8200