Healthcare Provider Details

I. General information

NPI: 1285814772
Provider Name (Legal Business Name): JARUM MICHAEL BOYER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 W 6TH ST SUITE 19 BLDG 440 US ARMY DENTAL ACTIVITY
FT STEWART GA
31314-4707
US

IV. Provider business mailing address

351 W 6TH ST SUITE 19 BLDG 440 US ARMY DENTAL ACTIVITY
FT STEWART GA
31314-4707
US

V. Phone/Fax

Practice location:
  • Phone: 912-767-6735
  • Fax: 912-767-5425
Mailing address:
  • Phone: 912-767-6735
  • Fax: 912-767-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number65942819921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number65942819921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: