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General NPI Number Information
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NPI Number | 1548349251
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Entity Type | Individual
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Provider Name | GREGORY SHANE JESSEN DDS
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Gender | Male
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Dates
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Enumeration Date | 11/03/2006
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Last Update Date | 10/17/2023
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Provider Practice Location Address
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Address Line | 1508 E SKYLINE DR STE 800
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City | OGDEN
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State | UT
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Zip | 84405-4889
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Country | US
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Telephone | 801-479-8200
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Fax | 801-479-3219
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Provider Business Mailing Address
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Address Line | 1508 E SKYLINE DR STE 800
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City | OGDEN
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State | UT
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Zip | 84405-4889
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Country | US
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Telephone | 801-479-8200
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Fax | 801-479-3219
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0004X
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Taxonomy Name | Dental Anesthesiology
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License Number | 5219929-9924
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number | 52199299924
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 5219929-9924
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License Number State | UT
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