Provider Demographics
NPI:1053872705
Name:QUIROZ, JORGE SAMUEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:SAMUEL
Last Name:QUIROZ
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 1:6087 S REDWOOD RD STE C
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-6854
Mailing Address - Country:US
Mailing Address - Phone:801-352-1300
Mailing Address - Fax:801-285-9170
Practice Address - Street 1:3725 W 4100 S STE 240
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5434
Practice Address - Country:US
Practice Address - Phone:801-965-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110551961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice