MEDICARE: JARED M WHITESIDE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	7818	NV

General Provider Information

NPI Number	:	1073201992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED M WHITESIDE DDS

Provider Business Mailing Address
First Line	:	10432 SADIE BLAKE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89166-6745
Country	:	US
Telephone Number	:	831-801-6594
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 N BUFFALO DR STE 110
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-7462
Country	:	US
Telephone Number	:	702-254-8858
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2023
Last Update Date	:	05/19/2023

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