Healthcare Provider Details

I. General information

NPI: 1073201992
Provider Name (Legal Business Name): JARED M WHITESIDE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 3RD ST E
HAMPTON SC
29924-2512
US

IV. Provider business mailing address

1083 DANNER DR
OKATIE SC
29909-6321
US

V. Phone/Fax

Practice location:
  • Phone: 803-943-2191
  • Fax:
Mailing address:
  • Phone: 831-801-6594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11334
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: