Provider Demographics
NPI:1083069561
Name:MAHONEY, JEREMY BRUCE (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BRUCE
Last Name:MAHONEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8846 S REDWOOD RD STE N201
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4702
Mailing Address - Country:US
Mailing Address - Phone:801-566-0631
Mailing Address - Fax:
Practice Address - Street 1:8846 S REDWOOD RD STE N201
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4702
Practice Address - Country:US
Practice Address - Phone:801-566-0631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
UT9823805-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program