Provider Demographics
NPI:1366014730
Name:DEBRINE, JASEN SCOTT
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:SCOTT
Last Name:DEBRINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 E 900 N STE A
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1244
Mailing Address - Country:US
Mailing Address - Phone:801-798-3526
Mailing Address - Fax:801-798-1186
Practice Address - Street 1:82 E 900 N STE A
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1244
Practice Address - Country:US
Practice Address - Phone:801-798-3526
Practice Address - Fax:801-798-1186
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT61100761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice