Provider Demographics
NPI:1780803361
Name:UTLEY, JERRY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
Last Name:UTLEY
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 1:401 GILLETTE ST
Mailing Address - Street 2:APT 303
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-4208
Mailing Address - Country:US
Mailing Address - Phone:608-498-1965
Mailing Address - Fax:
Practice Address - Street 1:1212 HORTON ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6372
Practice Address - Country:US
Practice Address - Phone:608-788-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60721223G0001X
MND113741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice