Provider Demographics
NPI:1780713974
Name:JARRELL, PATRICK D (DDS)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:D
Last Name:JARRELL
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 1:213 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1413
Mailing Address - Country:US
Mailing Address - Phone:304-574-2833
Mailing Address - Fax:304-574-2489
Practice Address - Street 1:213 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-574-2833
Practice Address - Fax:304-574-2489
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV35751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4002219000Medicaid
WV1580714OtherUNITED CONCORDIA PROVIDER