Provider Demographics
NPI:1548349251
Name:JESSEN, GREGORY SHANE (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:SHANE
Last Name:JESSEN
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 1:1508 E SKYLINE DR STE 800
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4889
Mailing Address - Country:US
Mailing Address - Phone:801-479-8200
Mailing Address - Fax:801-479-3219
Practice Address - Street 1:1508 E SKYLINE DR STE 800
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4889
Practice Address - Country:US
Practice Address - Phone:801-479-8200
Practice Address - Fax:801-479-3219
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5219929-99241223D0004X, 1223S0112X
UT521992999241223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223D0004XDental ProvidersDentistDental Anesthesiology
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870323919OtherTAX ID NUMBER
UT000012748Medicare ID - Type UnspecifiedMEDICARE ID NUMBER