Provider Demographics
NPI:1568525533
Name:YEARGAN, JODY LANE (DDS)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:LANE
Last Name:YEARGAN
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 1:711 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-4320
Mailing Address - Country:US
Mailing Address - Phone:434-409-5010
Mailing Address - Fax:
Practice Address - Street 1:545 E JOHNSON ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2856
Practice Address - Country:US
Practice Address - Phone:920-924-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106021223G0001X
WI10026931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice