Provider Demographics
NPI:1871888735
Name:NORDFELT, JED C (DMD)
Entity type:Individual
Prefix:DR
First Name:JED
Middle Name:C
Last Name:NORDFELT
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 1:4361 S PERIGRINE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5304
Mailing Address - Country:US
Mailing Address - Phone:502-759-9613
Mailing Address - Fax:
Practice Address - Street 1:6351 W 13400 S
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-5790
Practice Address - Country:US
Practice Address - Phone:801-302-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9474332-99221223P0221X
NY0562001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1871888735Medicaid
UT1871888735Medicaid