| NPI | 1104119601 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRETT R JACKSON Member 801-774-8198 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 6593716-9922) |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2011-05-17 |