Provider Demographics
NPI:1801177704
Name:JARDINE, MARK (DDS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:JARDINE
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 1:784 W 2920 N
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6022
Mailing Address - Country:US
Mailing Address - Phone:801-368-8674
Mailing Address - Fax:
Practice Address - Street 1:3330 N UNIVERSITY AVE STE A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4454
Practice Address - Country:US
Practice Address - Phone:801-615-2917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8544722-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice