Provider Demographics
NPI:1770152985
Name:JEREMY B MAHONEY DMD LLC
Entity type:Organization
Organization Name:JEREMY B MAHONEY DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:N
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-566-0631
Mailing Address - Street 1:8846 S REDWOOD RD STE N201
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4702
Mailing Address - Country:US
Mailing Address - Phone:801-566-0631
Mailing Address - Fax:801-566-4826
Practice Address - Street 1:8846 S REDWOOD RD STE N201
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4702
Practice Address - Country:US
Practice Address - Phone:801-566-0631
Practice Address - Fax:801-566-4826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154705960OtherINSURANCE CO