=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154525939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JARED THOMAS BUCK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 05/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1177 N DIVISION ST SUITE #1
-----------------------------------------------------
City | CARSON CITY
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89703-3874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-883-3434
-----------------------------------------------------
Fax | 775-885-9985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3953 BLAKE RD
-----------------------------------------------------
City | HUNTINGDON VALLEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19006-2318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-860-9283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | DS 037976
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | S7-70C
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------