Provider Demographics
NPI:1811144785
Name:MANDELARIS, JASON GERARD (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:GERARD
Last Name:MANDELARIS
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 1:275 W 200 N
Mailing Address - Street 2:175
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-5009
Mailing Address - Country:US
Mailing Address - Phone:801-769-2530
Mailing Address - Fax:
Practice Address - Street 1:275 W 200 N
Practice Address - Street 2:175
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-5009
Practice Address - Country:US
Practice Address - Phone:801-769-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7579613-99221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry