Provider Demographics
NPI:1164824868
Name:MOUNTS, JERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:MOUNTS
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:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:MATEWAN
Mailing Address - State:WV
Mailing Address - Zip Code:25678-0537
Mailing Address - Country:US
Mailing Address - Phone:304-426-4161
Mailing Address - Fax:304-426-4162
Practice Address - Street 1:1 MATE STREET
Practice Address - Street 2:
Practice Address - City:MATEWAN
Practice Address - State:WV
Practice Address - Zip Code:25678-0537
Practice Address - Country:US
Practice Address - Phone:304-426-4161
Practice Address - Fax:304-426-4162
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137275000Medicaid