Provider Demographics
NPI:1912926882
Name:THORNLEY, MARK JARED (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JARED
Last Name:THORNLEY
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 1:104 E 200 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4007
Mailing Address - Country:US
Mailing Address - Phone:435-752-9662
Mailing Address - Fax:435-752-9664
Practice Address - Street 1:104 E 200 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4007
Practice Address - Country:US
Practice Address - Phone:435-752-9662
Practice Address - Fax:435-752-9664
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5946318-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice