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General NPI Number Information
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NPI Number | 1801455597
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Entity Type | Individual
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Provider Name | JASON M GORDON DDS
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Gender | Male
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Dates
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Enumeration Date | 06/06/2019
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Last Update Date | 06/09/2020
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Provider Practice Location Address
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Address Line | 1963 S 1200 E STE 103
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-3523
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Country | US
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Telephone | 801-466-1212
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Fax |
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Provider Business Mailing Address
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Address Line | 4577 S 4000 W STE B
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City | WEST VALLEY
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State | UT
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Zip | 84120-6222
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Country | US
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Telephone | 801-895-2788
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Fax |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 11313905-9922
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License Number State | UT
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