Provider Demographics
NPI:1316152879
Name:JARVIS, WAYNE C (DDS)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:C
Last Name:JARVIS
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 1:2005 LYELL AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-2323
Mailing Address - Country:US
Mailing Address - Phone:585-254-5360
Mailing Address - Fax:585-254-8200
Practice Address - Street 1:2005 LYELL AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-2323
Practice Address - Country:US
Practice Address - Phone:585-254-5360
Practice Address - Fax:585-254-8200
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0359021223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ4000023068Medicare UPIN