Provider Demographics
NPI:1396030003
Name:BULLOCK, JERI LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:JERI
Middle Name:LYNN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1144 E FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1804
Mailing Address - Country:US
Mailing Address - Phone:801-566-3118
Mailing Address - Fax:
Practice Address - Street 1:1144 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1804
Practice Address - Country:US
Practice Address - Phone:801-566-3118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414490122300000X
VT016.00782671223G0001X
UT90-08098881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019260Medicaid