Healthcare Provider Details

I. General information

NPI: 1497850309
Provider Name (Legal Business Name): JEPPSON DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 N UNIVERSITY AVE STE 280
PROVO UT
84601-5658
US

IV. Provider business mailing address

86 N UNIVERSITY AVE STE 280
PROVO UT
84601-5658
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2946929922
License Number StateUT

VIII. Authorized Official

Name: DR. JOE C JEPPSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 801-356-7701