Provider Demographics
NPI:1356969307
Name:HASLAM, JACOB MARLAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MARLAN
Last Name:HASLAM
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 1:448 E 5350 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-5414
Mailing Address - Country:US
Mailing Address - Phone:801-479-1700
Mailing Address - Fax:
Practice Address - Street 1:448 E 5350 S STE C
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-5415
Practice Address - Country:US
Practice Address - Phone:801-479-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11747165-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice