Provider Demographics
NPI:1700362555
Name:JAEGER, STEPHEN (DMD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:JAEGER
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 1:620 13TH ST W APT 5
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-4807
Mailing Address - Country:US
Mailing Address - Phone:908-619-3119
Mailing Address - Fax:
Practice Address - Street 1:6850 UPPER BOX ELDER RD
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521-9073
Practice Address - Country:US
Practice Address - Phone:406-395-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADS041842Medicaid