Provider Demographics
NPI:1891073334
Name:SORENSEN, JAKE DANIEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:DANIEL
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SOUTH 380 EAST
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335
Mailing Address - Country:US
Mailing Address - Phone:435-213-6991
Mailing Address - Fax:
Practice Address - Street 1:40 W. CACHE VALLEY BLVD. #2A
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:435-787-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8021465-8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist