Provider Demographics
NPI:1720149453
Name:RUPP, JEFFERY K (DMD, MS)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:K
Last Name:RUPP
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 E 4500 S
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4209
Mailing Address - Country:US
Mailing Address - Phone:801-463-1900
Mailing Address - Fax:
Practice Address - Street 1:1548 E 4500 S
Practice Address - Street 2:SUITE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-4209
Practice Address - Country:US
Practice Address - Phone:801-463-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6273877-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry