Provider Demographics
NPI:1689950503
Name:SOUTHWELL, JARED MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JARED
Middle Name:MICHAEL
Last Name:SOUTHWELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4036
Mailing Address - Country:US
Mailing Address - Phone:805-657-2913
Mailing Address - Fax:
Practice Address - Street 1:3 ROAD 6523
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417-9452
Practice Address - Country:US
Practice Address - Phone:505-598-6800
Practice Address - Fax:505-598-6830
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist