Provider Demographics
NPI:1184839623
Name:WIDDISON, JOSEPH JACK (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JACK
Last Name:WIDDISON
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 1:1555 MAIN ST
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-5998
Mailing Address - Country:US
Mailing Address - Phone:970-690-9823
Mailing Address - Fax:
Practice Address - Street 1:1555 MAIN ST
Practice Address - Street 2:SUITE A-2
Practice Address - City:WINDSOR
Practice Address - State:CO
Practice Address - Zip Code:80550-5998
Practice Address - Country:US
Practice Address - Phone:970-690-9823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26396122300000X
CO9379122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist