Provider Demographics
NPI:1407239775
Name:TAVERNIER, JARED PRESTON (DMD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:PRESTON
Last Name:TAVERNIER
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 1:321 N CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NINETY SIX
Mailing Address - State:SC
Mailing Address - Zip Code:29666-1012
Mailing Address - Country:US
Mailing Address - Phone:864-543-4109
Mailing Address - Fax:
Practice Address - Street 1:321 N CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:NINETY SIX
Practice Address - State:SC
Practice Address - Zip Code:29666-1012
Practice Address - Country:US
Practice Address - Phone:864-543-4109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice