Provider Demographics
NPI:1801455597
Name:GORDON, JASON M (DDS)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:M
Last Name:GORDON
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 1:4577 S 4000 W STE B
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-6222
Mailing Address - Country:US
Mailing Address - Phone:801-895-2788
Mailing Address - Fax:
Practice Address - Street 1:1963 S 1200 E STE 103
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3523
Practice Address - Country:US
Practice Address - Phone:801-466-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11313905-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist