Provider Demographics
NPI:1871978981
Name:BOYACK, JACOB (DMD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BOYACK
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 1:2651 W SOUTH JORDAN PKWY STE 203
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8968
Mailing Address - Country:US
Mailing Address - Phone:801-254-5553
Mailing Address - Fax:
Practice Address - Street 1:2651 W SOUTH JORDAN PKWY STE 203
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8968
Practice Address - Country:US
Practice Address - Phone:801-254-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9410476-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice