=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295465946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JW DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 653 N TOWN CENTER DR SUITE 508
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-228-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11000 PINE KNOLLS CT
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89144-1652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-773-2752
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JADEN E WILLARD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 435-773-2752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------