Healthcare Provider Details

I. General information

NPI: 1841474160
Provider Name (Legal Business Name): M DOUGLAS JENKINS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4970 S 900 E SUITE G
SALT LAKE CITY UT
84117-5776
US

IV. Provider business mailing address

4970 S 900 E SUITE G
SALT LAKE CITY UT
84117-5776
US

V. Phone/Fax

Practice location:
  • Phone: 801-262-6811
  • Fax:
Mailing address:
  • Phone: 801-262-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number135199
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: