Provider Demographics
NPI:1275095630
Name:WARD, ONTARIO O'SHAWN (DDS)
Entity Type:Individual
Prefix:
First Name:ONTARIO
Middle Name:O'SHAWN
Last Name:WARD
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 1:125 CENTERSTONE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-1888
Mailing Address - Country:US
Mailing Address - Phone:731-363-6984
Mailing Address - Fax:
Practice Address - Street 1:2690 NE KRESKY AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2412
Practice Address - Country:US
Practice Address - Phone:360-330-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE61066574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program