Healthcare Provider Details

I. General information

NPI: 1922150457
Provider Name (Legal Business Name): JODIE KEVIN WARD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 COWARDLY LION DR STE C
HEDGESVILLE WV
25427-6779
US

IV. Provider business mailing address

71 COWARDLY LION DR SUITE C
HEDGESVILLE WV
25427-6779
US

V. Phone/Fax

Practice location:
  • Phone: 304-754-9008
  • Fax: 304-754-0098
Mailing address:
  • Phone: 304-754-9008
  • Fax: 304-754-0098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3109
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: