=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861183352
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK VARGA HADWIN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2023
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 17TH ST STE B-190
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80265-1050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-730-8236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 295 E SPEER BLVD APT 335
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-3562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-643-7940
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 00205574
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------