Healthcare Provider Details

I. General information

NPI: 1356553713
Provider Name (Legal Business Name): JASON NORMAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2007
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W 100 N
PROVO UT
84601-4433
US

IV. Provider business mailing address

589 SOUTH STATE STREET
PROVO UT
84606-5056
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9660
  • Fax:
Mailing address:
  • Phone: 801-429-2000
  • Fax: 801-429-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4747595-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: