Healthcare Provider Details

I. General information

NPI: 1780979138
Provider Name (Legal Business Name): DR. JEFFREY A IVERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E 9400 S STE 201
SANDY UT
84094-4118
US

IV. Provider business mailing address

850 E 9400 S STE 201
SANDY UT
84094-4118
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-9664
  • Fax: 801-571-9662
Mailing address:
  • Phone: 801-571-9664
  • Fax: 801-571-9662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY A IVERSON
Title or Position: ORTHODONTIST
Credential: D.M.D.,M.S.
Phone: 801-571-9664