Provider Demographics
NPI:1437762556
Name:WALKER, JARED A
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:A
Last Name:WALKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TECHNOLOGY PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-7122
Mailing Address - Country:US
Mailing Address - Phone:407-543-8509
Mailing Address - Fax:
Practice Address - Street 1:307 W WINNIE LN STE 2
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-2145
Practice Address - Country:US
Practice Address - Phone:775-885-2323
Practice Address - Fax:775-882-8989
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV73631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice