Provider Demographics
NPI:1043862279
Name:HAWTHORNE, JARED (DMD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:
Last Name:HAWTHORNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E 39TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2229
Mailing Address - Country:US
Mailing Address - Phone:360-694-7931
Mailing Address - Fax:
Practice Address - Street 1:117 E 39TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2229
Practice Address - Country:US
Practice Address - Phone:360-694-7931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61235268122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist