Provider Demographics
NPI:1316961162
Name:BARDEN, JON WILLIS (DDS)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:WILLIS
Last Name:BARDEN
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 1:2406 BELLEVUE RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2842
Mailing Address - Country:US
Mailing Address - Phone:478-272-7250
Mailing Address - Fax:478-272-7277
Practice Address - Street 1:2406 BELLEVUE RD
Practice Address - Street 2:SUITE 19
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2842
Practice Address - Country:US
Practice Address - Phone:478-272-7250
Practice Address - Fax:478-272-7277
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00044316AMedicaid