Provider Demographics
NPI:1528817897
Name:COAKLEY, JASON (DMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:COAKLEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11906 S ANTELOPE FLAT WAY
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-2701
Mailing Address - Country:US
Mailing Address - Phone:801-455-0320
Mailing Address - Fax:
Practice Address - Street 1:2183 W MAIN ST STE A301
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6763
Practice Address - Country:US
Practice Address - Phone:801-610-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13909840-99261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice