Provider Demographics
NPI:1659659589
Name:WILLIS, JARED HELAMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:HELAMAN
Last Name:WILLIS
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 1:10414 SE PINE ST
Mailing Address - Street 2:S107
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-4608
Mailing Address - Country:US
Mailing Address - Phone:347-308-3811
Mailing Address - Fax:
Practice Address - Street 1:2038 LLOYD CTR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1309
Practice Address - Country:US
Practice Address - Phone:503-288-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD96161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice