Healthcare Provider Details

I. General information

NPI: 1225358435
Provider Name (Legal Business Name): JAY D REDD D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 SANTA CLARA DR
SANTA CLARA UT
84765-5472
US

IV. Provider business mailing address

2301 SANTA CLARA DR
SANTA CLARA UT
84765-5472
US

V. Phone/Fax

Practice location:
  • Phone: 435-688-1577
  • Fax: 435-688-1578
Mailing address:
  • Phone: 435-688-1577
  • Fax: 435-688-1578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6670191
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: