Provider Demographics
NPI:1306092663
Name:MACK, JARED WAYNE (DDS)
Entity type:Individual
Prefix:MR
First Name:JARED
Middle Name:WAYNE
Last Name:MACK
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 1:624 S 1000 E STE 107
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5902
Mailing Address - Country:US
Mailing Address - Phone:435-289-6600
Mailing Address - Fax:435-289-6900
Practice Address - Street 1:624 S 1000 E STE 17
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5898
Practice Address - Country:US
Practice Address - Phone:435-289-6600
Practice Address - Fax:435-289-6900
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57690122300000X, 1223S0112X
390200000X
UT119590481223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program