Provider Demographics
NPI:1285728188
Name:JERRY MOUNTS DDS, INC
Entity type:Organization
Organization Name:JERRY MOUNTS DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUNTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-426-4161
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:MATEWAN
Mailing Address - State:WV
Mailing Address - Zip Code:25678-0537
Mailing Address - Country:US
Mailing Address - Phone:304-426-4161
Mailing Address - Fax:304-426-4162
Practice Address - Street 1:MATE STREET
Practice Address - Street 2:
Practice Address - City:MATEWAN
Practice Address - State:WV
Practice Address - Zip Code:25678
Practice Address - Country:US
Practice Address - Phone:304-426-4161
Practice Address - Fax:304-426-4162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0137275000Medicaid