Provider Demographics
NPI:1679627004
Name:SQUIRES, JEFFREY WALTER (DMD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WALTER
Last Name:SQUIRES
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 1:168 E 5900 SO
Mailing Address - Street 2:SUITE #101
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-266-8161
Mailing Address - Fax:801-281-7440
Practice Address - Street 1:168 E 5900 SO
Practice Address - Street 2:SUITE #101
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-266-8161
Practice Address - Fax:801-281-7440
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14104399221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice