Provider Demographics
NPI:1174132450
Name:JOHNSON, JASON C (DMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:JOHNSON
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 1:1231 W 9000 S.
Mailing Address - Street 2:SUITE #D
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5176
Mailing Address - Country:US
Mailing Address - Phone:801-999-4431
Mailing Address - Fax:801-878-7035
Practice Address - Street 1:1231 W 9000 S.
Practice Address - Street 2:SUITE #D
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5176
Practice Address - Country:US
Practice Address - Phone:801-999-4431
Practice Address - Fax:801-878-7035
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11683198-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty