Provider Demographics
NPI:1669016796
Name:JAFARIAN, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JAFARIAN
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 1:2971 CHAPEL VALLEY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2971 CHAPEL VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7420
Practice Address - Country:US
Practice Address - Phone:615-278-6445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11173122300000X
WI10027341223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No122300000XDental ProvidersDentist