Provider Demographics
NPI:1982612974
Name:HASLAM, JEFFREY ROBERT (DDS FAGD PC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ROBERT
Last Name:HASLAM
Suffix:
Gender:M
Credentials:DDS FAGD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5300 S ADAMS AVENUE PARKWAY
Mailing Address - Street 2:SUITE #4
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6966
Mailing Address - Country:US
Mailing Address - Phone:801-479-1700
Mailing Address - Fax:801-476-8305
Practice Address - Street 1:5300 S ADAMS AVENUE PARKWAY
Practice Address - Street 2:SUITE #4
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6966
Practice Address - Country:US
Practice Address - Phone:801-479-1700
Practice Address - Fax:801-476-8305
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1441461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice