Provider Demographics
NPI:1093876328
Name:TERRY, WILLIAM JARED (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JARED
Last Name:TERRY
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 1:2318 DOUGLAS ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1851
Mailing Address - Country:US
Mailing Address - Phone:415-858-4755
Mailing Address - Fax:
Practice Address - Street 1:2318 DOUGLAS ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-1851
Practice Address - Country:US
Practice Address - Phone:415-858-4755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26313122300000X
IDD-4033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist