Provider Demographics
NPI:1598716284
Name:JAGGER, WILLIAM J (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:J
Last Name:JAGGER
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 1:510 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2013
Mailing Address - Country:US
Mailing Address - Phone:719-543-1132
Mailing Address - Fax:719-543-1132
Practice Address - Street 1:510 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2013
Practice Address - Country:US
Practice Address - Phone:719-543-1132
Practice Address - Fax:719-543-1132
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO25941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02025948Medicaid
CO813547OtherUNITED CONCORDIA ID