Healthcare Provider Details

I. General information

NPI: 1871542480
Provider Name (Legal Business Name): JARED CRAIG CONDIE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR SUITE 100
U S A F ACADEMY CO
80840-2502
US

IV. Provider business mailing address

589 SOUTH STATE STREET
PROVO UT
84606-5056
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5190
  • Fax:
Mailing address:
  • Phone: 801-429-2000
  • Fax: 801-429-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8998
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6654264-9923
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: