Healthcare Provider Details

I. General information

NPI: 1285831990
Provider Name (Legal Business Name): MAURICE GUSTAF JENKINS D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 12/11/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RIVER PARK DR STE 360
PROVO UT
84604-5835
US

IV. Provider business mailing address

280 RIVER PARK DR STE 360
PROVO UT
84604-5835
US

V. Phone/Fax

Practice location:
  • Phone: 801-437-7701
  • Fax: 801-356-6326
Mailing address:
  • Phone: 801-437-7701
  • Fax: 801-356-6326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6700
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: