MEDICARE: JEFFERY K. RUPP D.M.D., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	6273877-9922	UT

General Provider Information

NPI Number	:	1720149453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFERY K. RUPP D.M.D., M.S.

Provider Business Mailing Address
First Line	:	1548 E 4500 S
Second Line	:	SUITE 102
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4209
Country	:	US
Telephone Number	:	801-463-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1548 E 4500 S
Second Line	:	SUITE 102
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4209
Country	:	US
Telephone Number	:	801-463-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	09/27/2012

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