Provider Demographics
NPI:1619436425
Name:TEPPER, JASON ANDREW
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:ANDREW
Last Name:TEPPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 S MCCLELLAND ST APT 548
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4455
Mailing Address - Country:US
Mailing Address - Phone:385-831-1131
Mailing Address - Fax:
Practice Address - Street 1:642 KIRBY LN STE 101
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5753
Practice Address - Country:US
Practice Address - Phone:801-798-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002257-151223G0001X
UT13788895-99241223S0112X, 204E00000X
MND143801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery