Healthcare Provider Details

I. General information

NPI: 1154525939
Provider Name (Legal Business Name): JARED THOMAS BUCK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 N DIVISION ST SUITE #1
CARSON CITY NV
89703-3874
US

IV. Provider business mailing address

3953 BLAKE RD
HUNTINGDON VALLEY PA
19006-2318
US

V. Phone/Fax

Practice location:
  • Phone: 775-883-3434
  • Fax: 775-885-9985
Mailing address:
  • Phone: 559-860-9283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDS 037976
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberS7-70C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: