Provider Demographics
NPI:1710011754
Name:JOHNSON, JARED C (DDS)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:C
Last Name:JOHNSON
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 1:1706 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2436
Mailing Address - Country:US
Mailing Address - Phone:208-678-2332
Mailing Address - Fax:208-677-8922
Practice Address - Street 1:1706 OVERLAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2436
Practice Address - Country:US
Practice Address - Phone:208-678-2332
Practice Address - Fax:208-677-8922
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-20791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice