Provider Demographics
NPI:1255171245
Name:MOSS, JACOB BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:BRIAN
Last Name:MOSS
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 1:2924 S GARDEN MEADOWS CV
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1302
Mailing Address - Country:US
Mailing Address - Phone:801-884-9386
Mailing Address - Fax:
Practice Address - Street 1:7632 S CAMPUS VIEW DR STE 150
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-5545
Practice Address - Country:US
Practice Address - Phone:801-282-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14004167-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice