Provider Demographics
NPI:1932328788
Name:WORDEN, JAY FREDERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:FREDERIC
Last Name:WORDEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:JAY
Other - Middle Name:FREDERIC
Other - Last Name:WORDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PC
Mailing Address - Street 1:304 6TH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:COULEE DAM
Mailing Address - State:WA
Mailing Address - Zip Code:99116-1335
Mailing Address - Country:US
Mailing Address - Phone:509-633-0700
Mailing Address - Fax:509-633-3063
Practice Address - Street 1:304 6TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:COULEE DAM
Practice Address - State:WA
Practice Address - Zip Code:99116-1335
Practice Address - Country:US
Practice Address - Phone:509-633-0700
Practice Address - Fax:509-633-3063
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000065381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5012968Medicaid