Provider Demographics
NPI:1902842321
Name:WHITE, JEREMY JACK (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JACK
Last Name:WHITE
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 1:594 E 800 S
Mailing Address - Street 2:SUITE G
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-6302
Mailing Address - Country:US
Mailing Address - Phone:801-765-1443
Mailing Address - Fax:
Practice Address - Street 1:594 E 800 S
Practice Address - Street 2:SUITE G
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-6302
Practice Address - Country:US
Practice Address - Phone:801-765-1443
Practice Address - Fax:801-722-0045
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5144673-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice