MEDICARE: DR. JARED DURHAM 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	18115	TX

General Provider Information

NPI Number	:	1134258908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JARED DURHAM DDS

Provider Business Mailing Address
First Line	:	1500 S MAIN ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-4917
Country	:	US
Telephone Number	:	817-921-3431
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 S MAIN ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76104-4917
Country	:	US
Telephone Number	:	817-921-3431
Fax Number	:

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

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	07/23/2008

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