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General NPI Number Information
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NPI Number | 1902271539
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Entity Type | Organization
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Legal Business Name | MATTHEW JACOBSEN PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 12/08/2015
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Last Update Date | 12/08/2015
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Provider Practice Location Address
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Address Line | 4019 W 12600 S STE 200
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City | RIVERTON
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State | UT
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Zip | 84096-7406
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Country | US
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Telephone | 801-302-7938
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Fax |
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Provider Business Mailing Address
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Address Line | 4019 W 12600 S STE 200
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City | RIVERTON
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State | UT
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Zip | 84096-7406
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Country | US
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Telephone | 801-302-7938
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. MATTHEW VAUGHN JACOBSEN
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Credential | DDS
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Telephone | 801-589-3150
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 83203479923
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License Number State | UT
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