Provider Demographics
NPI:1992838627
Name:JARDINE, BARRY WAYNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:WAYNE
Last Name:JARDINE
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 1:1910 S MERIDIAN RD
Mailing Address - Street 2:STE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9061
Mailing Address - Country:US
Mailing Address - Phone:208-888-3540
Mailing Address - Fax:208-888-3930
Practice Address - Street 1:1910 S. MERIDAN RD.
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4842
Practice Address - Country:US
Practice Address - Phone:208-888-3540
Practice Address - Fax:208-888-3930
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8069432Medicaid