Provider Demographics
NPI:1699916502
Name:JAMSTAN P C
Entity type:Organization
Organization Name:JAMSTAN P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-561-9999
Mailing Address - Street 1:204 FORT UNION BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-5645
Mailing Address - Country:US
Mailing Address - Phone:801-561-9999
Mailing Address - Fax:801-561-9979
Practice Address - Street 1:204 FORT UNION BLVD STE 102
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-5645
Practice Address - Country:US
Practice Address - Phone:801-561-9999
Practice Address - Fax:801-561-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT36635699211223G0001X
UT343288-99221223G0001X
UT343288-89031223G0001X
UT366356-89031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty