Provider Demographics
NPI:1497850309
Name:JEPPSON DENTAL
Entity Type:Organization
Organization Name:JEPPSON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:C
Authorized Official - Last Name:JEPPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:801-356-7701
Mailing Address - Street 1:86 N UNIVERSITY AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5658
Mailing Address - Country:US
Mailing Address - Phone:801-356-7701
Mailing Address - Fax:
Practice Address - Street 1:86 N UNIVERSITY AVE STE 280
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5658
Practice Address - Country:US
Practice Address - Phone:801-356-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2946929922261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1223G0001XOtherGENERAL DENTIST