Provider Demographics
NPI:1306031539
Name:DASTRUP, N. JARED (DDS)
Entity type:Individual
Prefix:DR
First Name:N.
Middle Name:JARED
Last Name:DASTRUP
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 1:5725 ERINDALE DR STE 106
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1984
Mailing Address - Country:US
Mailing Address - Phone:719-596-9220
Mailing Address - Fax:719-574-4567
Practice Address - Street 1:5725 ERINDALE DR STE 106
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918
Practice Address - Country:US
Practice Address - Phone:719-596-9220
Practice Address - Fax:719-574-4567
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10185122300000X
UT5341183-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice