Healthcare Provider Details

I. General information

NPI: 1912018185
Provider Name (Legal Business Name): JARRED KRISTIAN DONALD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CONRAD HILTON BLVD
CISCO TX
76437-3140
US

IV. Provider business mailing address

700 CONRAD HILTON BLVD
CISCO TX
76437
US

V. Phone/Fax

Practice location:
  • Phone: 254-442-2000
  • Fax:
Mailing address:
  • Phone: 254-442-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20077
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: