Provider Demographics
NPI:1619710084
Name:COLE, JAYSON MARK (DMD)
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:MARK
Last Name:COLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 E 25 S
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-1278
Mailing Address - Country:US
Mailing Address - Phone:435-851-9735
Mailing Address - Fax:
Practice Address - Street 1:2954 CARRINGTON RD
Practice Address - Street 2:FORT BLISS
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14006231-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist