Provider Demographics
NPI:1396033494
Name:WALLIS, JARED S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:S
Last Name:WALLIS
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 1:2540 N TELSHOR BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8201
Mailing Address - Country:US
Mailing Address - Phone:575-521-9375
Mailing Address - Fax:575-521-2637
Practice Address - Street 1:2540 N TELSHOR BLVD STE E
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8201
Practice Address - Country:US
Practice Address - Phone:575-521-9375
Practice Address - Fax:575-521-2637
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM35121223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice