Provider Demographics
NPI:1114134004
Name:CHANDLER, JASON G (DMD, MS)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:G
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2297 NO. HILLFIELD RD
Mailing Address - Street 2:STE. A105
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-779-0506
Mailing Address - Fax:801-779-4344
Practice Address - Street 1:2297 NO. HILLFIELD RD
Practice Address - Street 2:STE. A105
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-779-0506
Practice Address - Fax:801-779-4344
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7263018-99241223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1114134004Medicaid
UT1114134004Medicaid