Provider Demographics
NPI:1295848190
Name:JARVIS, REED K (DDS)
Entity Type:Individual
Prefix:DR
First Name:REED
Middle Name:K
Last Name:JARVIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:REED
Other - Middle Name:
Other - Last Name:JARVIS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 9507
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-0507
Mailing Address - Country:US
Mailing Address - Phone:208-322-8200
Mailing Address - Fax:208-322-7561
Practice Address - Street 1:9460 W FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-0500
Practice Address - Country:US
Practice Address - Phone:208-322-8200
Practice Address - Fax:208-322-7561
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-15261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002420900Medicaid
ID1526OtherIDAHO STATE DENTAL LICENSE