Provider Demographics
NPI:1477395994
Name:AREA DENTAL JEFFERSON, LLC
Entity type:Organization
Organization Name:AREA DENTAL JEFFERSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JARROD
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-285-9191
Mailing Address - Street 1:1149 BOUGHTON ST BLDG B
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3104
Mailing Address - Country:US
Mailing Address - Phone:920-285-9191
Mailing Address - Fax:
Practice Address - Street 1:846 E REINEL ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:WI
Practice Address - Zip Code:53549-9443
Practice Address - Country:US
Practice Address - Phone:920-674-6714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty