Provider Demographics
NPI:1184663718
Name:NORMAN, JED RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:RYAN
Last Name:NORMAN
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 1:1813 W HARVARD STE 221
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-672-6511
Mailing Address - Fax:541-673-1892
Practice Address - Street 1:1813 W HARVARD STE 221
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-672-6511
Practice Address - Fax:541-673-1892
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38311223G0001X
ORD88591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806926400Medicaid
OR278647Medicaid