Provider Demographics
NPI:1174636518
Name:GREAVES, JESSE N (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:N
Last Name:GREAVES
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 1:1401 E 3900 S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1475
Mailing Address - Country:US
Mailing Address - Phone:801-272-8051
Mailing Address - Fax:801-272-9109
Practice Address - Street 1:1401 E 3900 S
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1475
Practice Address - Country:US
Practice Address - Phone:801-272-8051
Practice Address - Fax:801-272-9109
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2778061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870570767HR1OtherEDUCATORS MUTUAL
KS0000838204OtherBCBS OF KS PROVIDER
UT314279OtherDMBA PROVIDER
1320390OtherUNITED CONCORDIA PROVIDER
46060OtherPEHP PROVIDER