Healthcare Provider Details

I. General information

NPI: 1083605711
Provider Name (Legal Business Name): JARED W. CARDON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
JBER AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-5026
  • Fax:
Mailing address:
  • Phone: 907-580-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3731
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3893-16
License Number StateMS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: