Healthcare Provider Details

I. General information

NPI: 1083069561
Provider Name (Legal Business Name): JEREMY BRUCE MAHONEY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8846 S REDWOOD RD STE N201
WEST JORDAN UT
84088-4702
US

IV. Provider business mailing address

8846 S REDWOOD RD STE N201
WEST JORDAN UT
84088-4702
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-0631
  • Fax:
Mailing address:
  • Phone: 801-566-0631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9823805-9922
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: