Provider Demographics
NPI:1154486751
Name:POWELL, JERALD NORMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERALD
Middle Name:NORMAN
Last Name:POWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 16TH ST
Mailing Address - Street 2:8E
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-351-6506
Mailing Address - Fax:970-351-8788
Practice Address - Street 1:3400 16TH ST
Practice Address - Street 2:8E
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-351-6506
Practice Address - Fax:970-351-8788
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice