Provider Demographics
NPI:1972761765
Name:PARKER, JEREMIAH J (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:J
Last Name:PARKER
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 1:18620 KNOLLWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8970
Mailing Address - Country:US
Mailing Address - Phone:571-275-8412
Mailing Address - Fax:
Practice Address - Street 1:10TH MEDICAL GROUP
Practice Address - Street 2:4102 PINION DRIVE
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80132
Practice Address - Country:US
Practice Address - Phone:571-275-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7025150-99211223E0200X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist