Provider Demographics
NPI:1649847310
Name:JORGENSEN, BRAIDEN DEMAR (DDS)
Entity type:Individual
Prefix:DR
First Name:BRAIDEN
Middle Name:DEMAR
Last Name:JORGENSEN
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:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:TETONIA
Mailing Address - State:ID
Mailing Address - Zip Code:83452-0071
Mailing Address - Country:US
Mailing Address - Phone:208-399-2723
Mailing Address - Fax:
Practice Address - Street 1:610 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8213
Practice Address - Country:US
Practice Address - Phone:307-732-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice